Preoperative Care PDF

PREOPERATIVE CARE Dr.Muhammad Abbas, Dr.Guo Xiaobin  WHAT IS THE PREOPERATIVE CARE Preoperative care refers to the physical and psychosocial care that prepares a patient to undergo surgery safely. The preoperative period begins when the patient is booked for surgery and ends with their...

PREOPERATIVE CARE Dr.Muhammad Abbas, Dr.Guo Xiaobin  WHAT IS THE PREOPERATIVE CARE Preoperative care refers to the physical and psychosocial care that prepares a patient to undergo surgery safely. The preoperative period begins when the patient is booked for surgery and ends with their transfer to the theatre or surgical suite.  INTRODUCTION PREOPERATIVE CARE 1. Preoperative care 2. Anesthesia and operation 3. Postoperative care  Diagnostic work-up Tolerance Preoperative well preparation Preoperative evaluation CLASSIFICATION OF OPERATION 1. Elective operation gastric or duodenal ulcer 2. Limitative operation cancer 3. Emergent operation rupture of the spleen PREOPERATIVE EVALUATION AND PREPARATION To assess the patient`s overall state of health To determine the risk of the impending surgical treatment To guide the preoperative preparation  General Health Assessment A. Complete history Present, past and family Such an evaluation, seeks to identify abnormalities that may influence operative risk or may bear on the patient’s future well-being B. physical examination A rectal examination should always be done C. Laboratory test Urine analysis, blood count, and chest X- rays ECG and stool test for occur blood for patients over 40 The adequacy of liver and kidney function should be tested if impairment is suspected Factors affecting operational risk Nonsurgical disorders frequently increase the risk of surgical procedures. Fatal complications are often related to preexisting organic disease, or to deficient immune and nutritional status. A. Nutrition Malnutrition increases the operative death rate Weight loss more than 20% caused by illness (Cancer, intestinal disease) Causes of inadequate nutrition B. Pulmonary dysfunction (hypoxia, atelectasis, pneumonia) Preoperative evaluation the degree of respiratory impairment History of heavy smoking and cough, obesity, advanced age, upper abdominal surgery, know pulmonary disease A chest X-ray, ECG, blood gases CO2 retention usually indicated severe pulmonary dysfunction (PaCo2 > 50mmHg) need for an elective operation, revaluated Preparation for respiratory system C. Cardiovascular system Risk of operation in cardiac patient is increased Symptoms: Contraindication: Preparation for cardiovascular system: D. Renal disease Not nearly so frequent as cardiovascular and respiratory diseases With appropriate hydration, renal complication of major surgery became relatively uncommon Screening of BUN (Blood urea nitrogen) creatinine determination and urinalysis. The most common cause of oliguria on surgical services is hypovolemia rather than renal failure. Strict attention to fluid balance To avoid drugs which are toxic to kidney Free drainage of the obstructed urinary tract Elimination of infection HEPATIC DISEASE Risk of operation is directly correlated with the child’s classification Cirrhosis patient, must be allowed recovery of function to be achieved Malnutrition, ascites, jaundice, child’s C’’ acute hepatitis DIABETIC DISEASE Every patient must be screened by a urine examination and blood sugar determination The ideal management consists of keeping the patient slightly hyperglycemic with a mild glycosuria Regular insulin should be indicated  3.PREOPERATIVE NOTES Written on the day before operation Pertinent findings and decisions Indications for the operation Discussion of the complications the risk of operation  Preoperative preparation 1.Psychologic preparation Cooperation with patient Appropriate explanation establishes confidence Surgeon’s responsibility to describe the planned procedure, risks, possible consequences, what will happen before, during, after operation 2.Operative permit sign in advance a permit authorizing Emergency life-saving operation 3.Skin preparation Shower or tab bath Shaving be performed immediately before surgery 4.Gastrointestinal preparation Omit solid food No food for 12 hours No liquids for 6-8 hours Nasogastric tube Poorly absorbed antimicrobial agents for colon operations Enemas need not be given routinely, except in the case of operations on the colon, rectum and anal regions 5.Fluid and blood volume When a patient is thought to be relatively hypovolemic before a major operation, preoperative intravenous hydration is indicated To correct anemia with packed red blood cells A significant fraction of the volume and concentration deficits should be replaced to enhance the safety of anesthetics and operation 6.Nutrition The oral administration of natural and specially prepared food is the best way to correct malnutrition Nasogastric tube feeding may also be useful In the absence of sufficient gastrointestinal function, specially prepared diets can be designed and may require total parenteral alimentation 7.Blood transfusion Have the patient typed and arrange for a sufficient number of units to be cross-matched 8.Bladder catheter Patient need hourly monitoring of urinary output during or after operation  POSTOPERATIVE CARE 1. An immediate or postanesthetic, recovery period 2. An intermediate care period 3. A convalescent period The Immediate Postoperative Period In the recovery room,until conscious and vital signs are stable. Intensive Care Unit (ICU) Specially need trained personal and equipment's for observation and treatment of acute pulmonary, cardiovascular, and fluid derangements Criteria for admission to the ICU a. Poor operative risks b. With severe respiratory cardiovascular, and renal problems tend to deteriorate rapidly c. Requiring frequent or continuous measurement of physiological variables 1.Monitoring a. Vital sign respiration and ECG b. CVP---Hypertension Borderline cardiac or respiratory function, Large amount of intravenous fluids c. Others---Cardiac arrhythmias, respiratory distress, wound bleeding or drainage, or impaired circulation in an extremity 2.Respiratiory care Intubated or supply oxygen by mask or nasal prongs Tracheal suction. Using of ventilator &Taking deep breaths frequently 3.Postion Lying flat, or on the side or sitting or having the foot of bed elevated Turn side to side every 1-2 hours Active motion of the feet and legs 4.Renal and bladder function Urine output measurement>30ml/hour Void within 6-8 hours after operation 5.Administration of fluid and electrolytes Nothing by mouth for 6-8 hours Maintaince intravenous fluids and replacement fluids for drainage losses A summary of intake and output and the amount of blood lost and replacment should be balanced 6.Drainage tube To prevent accumulation of fluid or to remove pus, blood air,or other fluids Connect to suction or be irrigated with aseptic technics Check drainage fluids, quantity and quality Complications of drain Perforation, infection, hemorrhage, hernia, and loss of a drain 7.Medications Antibiotics, sedatives and drugs for pain relief Continuation of preoperative medications should be reordered 8.Special laboratory examination Hematocrit, Blood chemistry, ABG Aterial Blood gas analysis, Chest roentgenography (portable) THE INTERMEDIATE POSTOPERATIVE PERIOD Start with complete recovery from anesthesia and extends for the rest of the hospital stay. The patient recovers most basic functions and becomes self-sufficient and able to continue convalescence at home 1.Care of the wounds Sterile dressings Sutures Head, face and neck Lower abdominal and perineal region Chest, upper abdomen, and back Extremities  Classification of incisions 1. for sterile incision and thyroidectomy 2. for possibly contaminated incision as gastrectomy 3. for contaminated incision as laparotomy for gastric ulcer perforation Classification of wound healing a. for excellent healing b.for imcomplete healing with hematoma,seroma,or imflammation but no pus c.for pus formed in the wound needing drainage To leave the skin and subcutaneous tissues open for a wound has been contaminated with bacteria 2.Postoperative fluid and electrolyte management a. Maintenance requirement (1500- 2500ml)(30ml/kg) b. Extra need c. Losses from drains d. Requirement resulting from tissue edema and ileus Measurement of electrolytes in complicated cases 3.Postoperative care of the gastrointestinal tract peristalsis temporarily decreased Nasogastric tube Fasting for another 24 hours after the nasogastric tube has been withdrawn May be allowed to resume a regular diet after operations other than peritoneal cavity 4.Postoperative pain Influenced factors: Management of postoperative pain a.Patient-physician communication Close attention to patient's needs, frequent reassurance,and genuine concern b.Narcotics c.Other analgesic drugs 5.Fever Fever is a normal response to even minimal trauma, common after surgery Especially during the first 3 days not as significant as fever in non-operated patients The differential diagnosis of fever in following days includes catheter-related phlebitis, pneumonia, and urinary tract infection or wound infection Less common problems are anastomotic breakdown and intra-abdominal abscesses Treatment: Location of any source of infection Identification of the infecting organisms Surgical drainage and antibacterial therapy 6.Urinary retention Inability to void postoperatively is common, especially after pelvic and perineal operations or under spinal anesthesia Capacity of 500ml is exceeded, the bladder may be unable to contract and empty itself The patient should be encouraged to void as soon after surgery as possible The treatment of acute urinary retention is catheterization of the bladder POSTOPERATIVE COMPLICATIONS Any deviation from the uneventful postoperative recovery course is a postoperative complication When planning a surgical procedure ,it is wise to “ Hope for the Best Prepare for the Worst’’ Complications may result from the primary disease,the operation or other unrelated factors Complications can be minimized with rigorous preoperative evaluation, meticulous operative technique and careful monitoring of the patient’s progress with adequate management 1.Postoperative bleeding Bleeding is the most common cause of shock in the first 24 hours after surgery Postoperative bleeding is usually the result of a technical problem with homeostasis Its manifestations are those of hypovolemia: The diagnosis is often overlooked Re-exploration based on the fact that the patietn is not responding satisfactorily to the transfusions have been given 2.Wound complications a.Hematoma A collection of blood and clots in the wound Causing factors:Imperfect hemostasis, anticoagulants,vigorous coughing,and hypertension Signs:Elevation and discoloration of the wound edges,discomfort and swelling, blood leaks through skin sutures Neck Hematoma may expand rapidly and compress the trachea Treatment: Evacuation clot ,ligation of bleeding vessels, and gentle compression of the wound B. Wound infection A collection of pus in the wound. a minor wound or a major wound infection One major complication that may lead to significant morbidity and mortality Wound infection may lead to other problems such as wound dehiscence, fever and septicemia To obtain a sample of pus or exudate: Needle aspiration or removal of several sutures with direct culture. The incision should be opened widely to allow free drainage if it is found to be infected C. Wound dehiscence Partial or total disruption of any or all layers of the operative wound Systemic risk factors: Malnutrition, cancer and diabetes, immunosuppression, obese patient Local risk factors: Inadequacy of closure, increased intra- abdominal pressure and deficient wound healing Signs: Discharge of serosanguineous fluid from the wound, or sudden evisceration. (Popping sensation with severe coughing) Evisceration: Rupture of all layers of the abdominal wall and extrusion of abdominal viscera Management: With evisceration, any exposed bowel or omentum should be rinsed and then return to the abdomen mechanical cleansing and copious irrigation, reclosure of the wound using full-thickness sutures 2.Respiratory complications The largest single cause of complications after major surgical procedures Higher incidence in chest and upper abdominal operations Special hazards are posed by preexisting chronic obstructive pulmonary disease (chronic bronchitis,emphysema,chronic asthma) a. Atelectasis The most common pulmonary complication, affects 25% of patients who have abdominal surgery Self-limited and recovery uneventful Manifestation: fever,tachypnea,and tachycardia Signs: scatered rales,decreased breath sounds and elevation of diaphragm Prevention: Early mobilization, frequent changes in position, encouragement to cough Treatment: Clearing the airway: chest percussion, coughing, nasotracheal suction, and intrabronchial suction Nebulizer: bronchodilator and mucolytic agents B. Postoperative pneumonia Predisposing factors: atelectasis, aspiration and copious secretions Manifestations: fever, tachypnea, increased secretions, and physical signs of pulmonary consolidation Treatment: maintaining the airway clear of secretion, and adminstration of antibiotics 4.Urinary tract infection Preexisting contamination of the urinary tract urinary retention and instrumentation Cystitis is manifested by dysuria and mild fever, and pyelonephritis by high fever, flank tenderness Prevention involves treating urinary infection before surgery, prevention of urinary retention and careful instrumentation when needed Treatment includes adequate hydration, proper drainage of the bladder and specific antibiotics 5.Alimentary tract complications Following laparotomy,the normal propulsive activity of the intestinal tract is temporarily depressed Gastric peristalsis returns 24-48 hours after surgery, colonic activity returns 48 hours. Postoperative ileus leads to slight abdominal distention Return to normal peristalsis: as mild cramps,recover from bowel sound, passage of flatus, return of appetite Gastric dilatation A life-threatening complication, but rare, massive distention of the stomach by gas and fluid Predisposing factors: Gastric outlet obstruction (pyloric spasm),air inflation, severe shock with hypokalemia, acidosis and splenectomy Collapse of the lower lobe of the left lung,rotation of the heart,and obstruction of the inferior vena cava A great amount of fluid and electrolytes accumulated into stomach may result in severe dehydration and hypochloremia, hypokalemia and alkalosis The patient appears quite ill with abdominal distension and hiccup Treatment: Early gastric decompression with a nasogastric tube. In the late stage, gastric necrosis may require gastrectomy As a doctor never make early statement without evidence ! 谢谢！