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1、围手术期处理围手术期处理Management of Perioperative periodPre-Op and Post-Op Care Cancer Statistics, 2011. CA CANCER J CLIN 2012.Cancer Statistics, 2011. CA CANCER J CLIN 2012.Preoperative preparation术前准备术前准备Postoperative management术后处理术后处理Postoperative complications并发症处理并发症处理Emergency operationTrauma with mass
2、ive bleeding acute intracranial hematoma with brain hernia Acute arterial embolismAbdominal hollow cavity organ rupture or perforationBowel obstruction with blood insufficiencyConfine/Selective OperationConfine operationvRadical dissection of malignancySelective operationvHernia repair, benign tumor
3、 resectionPreoperative general preparationOperation agreement Smoking cessationDigestive tract preparationAntibioticsNutritional supplementBlood preparation Skin preparationDiet before surgeryPreoperative assessmentCardiac riskPulmonary riskHepatic riskNutritional riskMetabolic riskCardiacvascular r
4、iskEjection fraction, 35%Arrythmia, ventricular rate5/min, rhythm other than sinus, aortic valvular stenosis, age70,chest or abdominal surgery, EmergencyvECG, DCG, Ultrasonic/heartpulmonary riskSmokingCOPDvPulmonary function testvBlood gasvHigh PCO2 and low FEV1Hepatic riskBilirubin, serum albumin,
5、Prothrombin time, ascitis, encephalopathy 40% mortality with either Bilirubin2, Albumin16 or encephalopathy80%-85% mortality with three of above present, or Bilirubin4 or Albumin150Nutritional riskLoss of 20% of body weight in months Serum Albumin3Anergy to skin antigenSerum transferrin 200mg/dlNutr
6、itional support preferably via gut at least 4-5 daysMetabolic riskHyperglycemiaCorrection of acidosis change to insulin injection a little bit higher than normal is preferable 5.611.2mmol/LTest :blood glucose (Fasting+ after meal)Postoperative managementMonitorMonitorVital sign (HR,R,T,Bp,SpO2)Vital
7、 sign (HR,R,T,Bp,SpO2)General appearance( alertness, distress, pain,)General appearance( alertness, distress, pain,)painpainUrine volumeUrine volumedrainagedrainageWoundWoundDietDietActivityActivityExample Gastroectomy 50KgTPN Infusion 20003000ml total volume10002000KcalFor example： 50%glucose 200ml
8、,10%GS500ml,5%GNS 1000ml,Amino acid 500ml, Fat emulsion250mlOral fluid intake 3-4 days after pass wind, semi fluid 5-6 days 3-5 days remove drainage7-9 days remove sutureWound: when to remove sutureHead and neck: 4-5 daysLower abdominal and perineum : 6-7 daysChest, upper abdominal, back : 7-9 daysE
9、xtremities : 10-12 daysTension reducing suture : 14 daysAged, diabetes, malnutrition, delayedWound recording/gradingWound typevcleanv probable contaminated, GI tract, Respiratory tract, Genital/Urinary tractv contaminated, perforation, cellulitisHealingv甲级甲级v乙级乙级 inflammation，fluid retentionv丙级丙级inf
10、ectionRecordingAcute appendicitis with perforationv/甲甲Postoperative complicationsFeverFeverPulmonary complicationPulmonary complicationChest painChest painDisorientation/comaDisorientation/comaUrinary complicationsUrinary complicationsAbdominal distentionAbdominal distentionFluid and electrolytesFlu
11、id and electrolytesFeverBacteremiav30-45min after invasive procedurevChills and temperature spikevWorkup: blood culture, antibioticsAtelectasisPneunomiaUninary tract infectionDeep venous thrombophlebitisWound infectionDeep abscess“Wind, Water, Walk, Wound”Pulmonary complicationPulmonary complication
12、AspirationvAwake intubation with full stomachIntraoperative tension pneumothoraxvTB, pulmonary bleb +positive pressure breathingChest painChest painPerioperative myocardial infarctionvST depression, T-wave flatteningvTroponin,EKG,CK-MBPulmonary embolusvImmobilized patient, sudden onset, shortness of
13、 breath, tachycardic,vABG, Pulmonary angiogram, CT with contrastDisorientation/comaDisorientation/comaHypoxiaAdult respiratory distress syndromevOften complicated by sepsisvBilateral pulmonary infiltrates with no CHFDeliriumHyponatremiavLarge fluid intake, rapidly lowering sodiumHypernatremiavPituit
14、ary operation with diabets insipidusAmmonium intoxicationvCirrhotic patient with bleeding varices undergoes portocaval shuntUrinary complicationsUrinary complicationsPostoperative urinary retentionCatheterization if no urine 6 hour post-opZero urine output vPlugged catheterLow urinary outputvFluid d
15、eficitvAcute renal failurevFluid challenge: IV 500ml in 10minAbdominal distentionAbdominal distentionParalytic ileusvExpected in a few days post-op,hypokalemiaEarly mechnical bowel obstructionOgilvie syndromevParalytic ileus of the colonvElderly sedentary patientsvX-ray show massively dilated colonF
16、luid and electrolytesFluid and electrolytesHypokalemiaPotassium lost from GI tract, urine (loop duretics),move into cellsMetabolic acidosisvProduction of fixed acid, loss of buffers (bicarbonate rich fluid loss inGI),renal failurevLow PH,low bicarbonate,vTreat underlying cause, bicarbonate adminMale
17、 ,43 sudden onset of pain on lower abdominal for 2 hour with vomitingStrangulated hernia and bowel obstructionMale， 45， transfered stomachache 6 hoursAcute appendicitisFemale 85 increasing Abod Pain 2 daysStrangulated intestinal obstructionFemale, 60, fatigue for 2 monthsFemale, 53, breast mass a weekBreast cancerGastric cancerMale ,45 , shortness of breath and stomachache after stabbing on chest 1 hours agoPericardial blood effusion and temponade,gastric ruptureThank you!Contact information:浙医一院肿瘤中心，肿瘤外科浙医一院肿瘤中心，肿瘤外科 滕理送教授滕理送教授 王海勇王海勇
