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PerioperativeManagementPerioperativeperiodDefinitionnotwellestablishedImportancedirectlyrelatedtotheoutcomeofsurgeryitselfCompositionpreoperativepreparation&postoperativemanagement

1.Electivesurgery2.Restrictivesurgery3.EmergentsurgeryPreoperative

PreparationTheprincipleDifferentpreparationfordifferentoperationTheclassificationofoperationsaccordingtothecharacteristicsofoperationsToconfirmthediagnosisToassesstheriskofoperationToassessthegeneralconditionandfunctionofimportantorgansToevaluatethepatientsendurancetotheoperationandriskofoperationPreoperativeAssessmentEssentialstepsinpreoperative

assessmentandpreparationHistorytakingPhysicalexaminationCollatingpre-admissioninformationaboutdiagnosisArranginganyfurtherdiagnosticinvestigationMakingspecialpreparationsfortheparticularoperationInvestigatinganyintercurrentoroccultillnesssuggestedbymedicalclerkingEssentialstepsinpreoperative

assessmentandpreparationDiscussingtheoperationwiththepatientandhisfamilyandobtainingsignedconsentMarkingtheoperationsiteMakingarrangementsfortheoperationwiththeoperatingtheatrestaffArrangingandinformingtheanaesthetistPrescribingmedicationprophylacticantibioticsetc.PlanningrehabilitationandconvalescencePsychologicalpreparationtalkfranklyandappropriatelytopatientsPhysiologicalpreparationAdaptiveexerciseTransfusionPreventionofinfectionGastro-intestinaltractpreparationMaintenanceoffluid,electrolyteandnutritionGeneralPreparationMalnutritionanddysfunctionofimmunesystem

MalnutritiondramaticallyincreasesthemorbidityandmortalityPreoperativenutritionalsupportismorevaluableSpecificPreparationHypertension

Mild-to-moderateessentialhypertension

systolicpressure＜180mmHg

diastolicpressure＜

110mmHg

AtminimalriskofcardiaccomplicationAntihypertensivedrugsshouldbeusedalltimeSuddenwithdrawalofdrugsisdangerousSevereorpoorlycontrolledhypertension

Athighriskofperioperativecardiacfailureorstroke.Thistypeofpatientsshouldnotundergogeneralanaesthesiaandsurgeryuntiladequatelytreated.Thebloodpressureshouldbereasonablycontrolledunder160/100mmHg.Cardiovasculardisease

IschaemicheartdiseaseCardiacfailureArrhythmias

Valvularheartdisease

CerebrovasculardiseaseAnginaPreviousinfarctionStableanginaposeslittleincreasedriskduringoperationbutunstableanginaisasdangerousasrecentmyocardialinfarction

Theriskofreinfarctionisabout30%ifanoperationisperformedduringthefirst3monthsAt6monthstheriskisabout10~15%whichmaybeacceptableforimportantelectivesurgeryAdequatepreparationforheartdisease

Tocorrectthefluidandelectrolyteimbalance.Tocorrectanaemiathroughseveralbloodtransfusionwithsmallamount.Tocontrolthecardiacarrhythmias.

(Atrialfibrillation,Tachycardia,Bradycardia)Respiratorydysfunction

Respiratorycomplicationsoccurinupto15%ofsurgicalpatientsandaretheleadingcauseofpostoperativemortalityintheelderly.RiskfactorsforrespiratorycomplicationChronicobstructivepulmonaryorairwaysdisease(Chronicbronchitis,emphysema,bronchiectasis,pneumoconiosis,pulmonarytuberculoses)CigarettesmokingCurrentrespiratoryinfectionsAsthmaPreoperativeinvestigationofrespiratorydisease

AchestX-ray,CTscanifnecessaryEKG

SpirometerBloodgasmeasurementPerioperativemanagementofrespiratorydiseaseandhighriskpatients1.Preoperativephysiotherapyteachingthepatientbreathingexercisesandcorrectposture2.Drugtherapy

TheophyllinesProphylacticantibioticsPreoperativebronchodilatorAdequatehydration3.Encouragetostopsmokingfromthetimeofbookforelectivesurgery4.Alternationmethodsofanaesthesia

Local,regionalorspiralanaesthesiashouldbeconsidered5.

Earlypostoperativephysiotherapy

toenhancedeepbreathing,coughingandgeneralmobility

Liverdisorder

Thetolerancetooperationdependsupontheseverityofliverfunctionimpairment.TheliverfunctioncouldbeestimatedbyChildstaging.Malnutrition,ascitesandjaundicearecontraindicationsexceptforemergencysurgery.

Preoperativeassessmentandmanagement

SerologicaltestforHBVandHCV,fullbloodcount,clottingscreenandplateletcount,plasmaureaandelectrolytes,bilirubin,transaminases,calcium,phosphate,gammaglutaryl

transferase

andalbumin.Whenprothrombintimeisprolonged,vitaminKshouldbegivenforseveraldaysbeforeoperation.RenaldisordersPreoperativeassessmentplasmaurea,electrolytes,creatinineandBicarbonateshouldbecheckedMildchronicrenalfailureDrugsshouldbegiveninsmallerdosesFluidandelectrolytehomeostasisModerate-to-severechronicrenalfailureOperationsshouldbeperformedunderhaemodialysis

DisordersofAdrenalFunctionAdrenalInsufficiencyThemostcommoncauseofadrenalinsufficiencyishypothalamo-pituitary-adrenalsuppressionbylong-termcorticosteroidtherapy.Thelackofadrenalresponseinthesepatientsmaycauseacutepost-operativecardiovascularcollapsewithhypotensionandshock.Foranysteroid-dependentpatient,adoctorshouldwriteclearlyinthenote“Treatanyunexplainedcollapsewithhydrocortisone”.DiabetesMellitusAtspecialriskfromgeneralanaesthesiaandsurgery

Patientswithdiabetesfallintothreegroups1.Insulindependent2.Takingoralhypoglycaemicmedication3.Diet-controlled

Attempttomaintainbloodglucoselevelbetween4and10mmol/L,avoidhypoglycemiainparticular.Bloodglucoselevel＞13mmol/L,an

unreceptibleriskofketoacidosisora

hyperosmolarnon-ketoticstate.PerioperativemanagementThegeneralprincipleofperioperativemanagementEstablishgooddiabeticcontrolbeforeoperationGiveninsulinasacontinuousintravenousinfusionduringtheoperativeperiodGivenaninfusionofdextrosethroughouttheoperativeperiodtobalancetheinsulingivenandtomakeupforlackofdietaryintakeThegeneralprincipleofperioperativemanagementAddpotassiumtothedextroseinfusionMonitorbloodglucoseandelectrolytesfrequentlythroughouttheoperativeandearlypostoperativeperiod

Recoveryroomisnecessary

ICUisoptimalifpossibleMonitoring

CloselymonitorthelifesignsasaroutineCVPmonitoringisnecessaryifhemodynamicunstableduringoperationOtheritemsmonitoredaccordinglyFluidbalancePost-operativeManagementPositionandgettingup

Supinepositionforspiralanaesthesia

Semirecliningpositionforneckandchestoperation.Lateralpositionforobesitypatients.GetupasearlyaspossibleandmakemovementsasmuchaspossibleDietandtransfusion

Periodoffastdependsuponthetypeofoperation.

Enteralandparenteralnutritionshouldbetakenintoconsideration.Fluidandelectrolyteshomeostasisshouldbemaintained.ManagementofDrainageDifferentdrainagefordifferentpurpose(infectionfocus,leakagepreventionandmassiveexudation)Nasal-gastrictubeUrinarycatheterWoundhealingandsutureremovingClassificationofincisioncleanincisioncontaminatedincisioninfectedincisionTypeofhealing

TypeAperfecthealingBsomeinflammationCinfected1.Postoper

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