lp rac + pregatire preop
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Riscul Anestezico Chirurgical
Pregatirea pacientului pentru operatie
Explorarea intraoperatorie
Dr. Daha Claudiu
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Schema Adriani
I Bolnav tnr sau de vrst mijlocie, fr tare organice la carese face o intervenie chirurgical mic sau mijlocie ;
II Bolnav cu boli compensate sau care nu pune problemedeosebite de reechilibrare, la care se va practica o operaie
major ;
III Bolnav cu tare organice avansate care nu snt mortaleimediat i care va suferi o intervenie major ;
IV Bolnav decompensat care va fi supus unei interveniimajore ;
V Operaii de urgen la bolnavii din grupele I i II ;
VIOperaii de urgen la bolnavii din grupele III si IV.
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Clasificarea ASA
Medical co-morbidity increases the risk associated with
anaesthesia and surgery
American Society of Anesthesiologists (ASA) grade is the most
commonly used grading system
ASA accurately predicts morbidity and mortality
50% of patients presenting for elective surgery are ASA grade 1
Operative mortality for these patients is less than 1 in 10,000.
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Clasificarea ASA
ASA Grade Definition Mortality (%)
I Normal healthy individual 0.05
II Mild systemic disease that does not limit activity 0.4
III Severe systemic disease that limits activity but is not incapacitating 4.5
IV Incapacitating systemic disease which is constantly life-threatening 25
V Moribund, not expected to survive 24 hours with or without surgery 50
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Investigatii preoperatorii
De rutina:
HLG + VSH
Biochimie
ECG
RX pulmonar
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Investigatii preoperatorii suplimentare
Sunt necesare daca:
examenul clinic deceleaza elemente patologice
probabilitatea existentei unei patologii asociate
asimptomatice
chirurgie majora -interventii complexe
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Pregatirea pacientului pentru operatie
Operaie + anestezie = agresiune asupra organismului
totalitatea gesturilor ntreprinse pentru a diminua efectele
actului operator, ale anesteziei i ale traumei psihicesurvenite.
Pregtirea preoperatorie:
msuri de ordin general ce sunt aplicate tuturor pacienilor msuri particulare, necesare unei anumite categorii de bolnavi
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Masuri cu caracter general
Pregatirea psihica
Igiena bolnavului
Golirea intestinului
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Pregatirea psihica
Asigurarea confortului (rezerva curat, luminat, ferita dezgomote, nclzit n jur de 2022C, aerisita, etc)
Cucerirea ncrederii bolnavului de ctre personalul medico-
sanitar, informare - consimtamant
Ridicarea moralului, inlaturarea fobiilor, restabilirea
echilibrului psihic (psihoterapie eventual consult psihologic /
psihiatric - amputatii, mastectomii, transplant, etc)
Sedarea bolnavilor hiperreactivi, agitai, volubili, ct i a
celor apatici, descurajai prin administrarea de barbiturice
sau tranchilizante minore.
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Igiena bolnavului
Imbaierea i schimbarea lenjeriei este obligatorie
Pregatirea tegumentelor In dimineaa interveniei
radere n regiunea unde se va efectua intervenia chirurgical,
spalarea cu detergent i
iodare, eventual pansament steril
Asanarea focarelor septice (dentare, cutanate, etc)
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Golirea intestinului
Regim hidric cu 24h inainte
Oprirea lichidelor cu minim 6h inainte
Laxative cu 24h inainte
Clisma evacuatorie (seara dinaintea operatiei)
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Pregtirea aparatului sau organului Aparat respirator
aspirare secretii bronsicemucolitice, antibiotice
intubare selectiva cu sonda Carlins
Esofag Stomac
aspiratie
eventual spalatura
Colon
dieta purgative (Fortrans, Manitol, ulei de ricin)
clisme
antibiotice
Aparat genital - spalatura vaginala cu antiseptice
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Msuri particulare - bolnavi tarati - risc crescut
Obezitate
Denutriti, hipoproteici
Boli cardiovasculare
Afectiuni pulmonare
Patologie digestiva
Insuficienta renala Diabet
Afectiuni hematologice (anemie, tulburari de coagulare)
Imunosupresie
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Obezitate
Morbidity and mortality after all surgery is increased in the obese
Risk is increased even in the absence of other disease
Body mass index (BMI) is best measure of degree of obesity
BMI = Weight (Kg) / height (m)2
Normal BMI = 22-28
BMI greater than 28 equates to significantly overweight
BMI greater than 35 equals morbid obesity
Patients are at risk of numerous complications
Surgical prophylais for prevention of Deep Vein Thrombosis
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Denutriti, hipoproteici
bolnav cu pierdere ponderala, masa musculara i esutul grsos diminuat
foarte mult, palid, edeme i tulburri trofice ale tegumentelor, fora fizica iintelectualsczute mult.
Reechilibrarea trebuienceput prin corectarea hipoproteinemici:
transfuzia de snge integral aduce proteine, hemoglobina i hematiile
plasm sanguin n cantitate de200300 ml pe zi, timp de cteva zile,
hidrolizatele proteice - administrare oral sau i.v., se pot resintetiza n organism maiales cnd se administreaz mpreuna cu glucoza ;
acizi aminai administrai n soluie glucozat 5% i.v., de tipul Salviamin, Aminofuzin etc,
contribuie la refacerea bilanului azotat
lipidele eseniale, folosite n perfuzie contribuie la reducerea consumului de proteine n
scop caloric, ele avnd o valoare caloric dubla,
-soluii cristaloide (glucoza, lichide hidroelectrolitice) care au rolul de a redresa echilibrul
ionic al mediului intern.
echilibrarea unui bolnav denutrit necesita aportul caloric de peste30003500
calorii/zi prin perfuzia de lichide sau diverselor alimente trebuie
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Riscul cardiovascular Several scoring systems exist for stratifying cardiac risk prior to non-cardiac surgery
Simple to use and identify patients in need of further investigation Eagle index
One point allocated for each of:
o History of myocardial infarction of angina
o Q wave on preoperative ECG
o Non-diet controlled diabetes mellitus
o Age more than 70 years
o History of ventricular arrhythmia
If total score is:
o No points = low risko 1 or 2 points = intermediate risk
o More than 2 points = high risk
Low risk patients require no further investigation
Intermediate risk patients require exercise ECG and echo
High risk patients require coronary angiography prior to major surgery
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Myocardial Infarction
Elective surgery should be deferred for 6 months after a myocardial
infarct Risk factors for postoperative myocardial re-infarction:
o Short time since previous infarct
o Residual major coronary vessel disease
o Prolonged or major surgery
o Impaired myocardial function
Risk or postoperative re-infarction after a previous MI is:
o 0-3 months is 35%
o 3-6 months is 15%
o More than 6 months is 4%
60% of post operative myocardial infarcts are silent
The mortality of re-infarction is approximately 40%
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Hypertension
In patients with hypertension need to assess
o Degree of hypertension
o Presence of end organ damage
Risk of cardiovascular morbidity is increased in untreated orpoorly controlled hypertension
Risk is present if diastolic pressure is greater than 95 mmHg
Elective surgery should be cancelled if diastolic pressure is
greater than 120 mmHg
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Respiratory disease
Patients with lung disease are at increased risk of respiratory complications
The complications include:
o Bronchospasm
o Atelectasis
o Bronchopneumonia
o Hypoxaemia
o Respiratory failure
o Pulmonary embolism
In addition to routine preoperative investigations need to consider
o Chest radiography
o Spirometryo Arterial blood gases
Upper respiratory tract infections increase the risk postoperative chest complications
Elective surgery should be deferred for 2-4 weeks
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Smoking
Doubles the risk of pulmonary complications
Increased risk persists for 3-4 months after
stopping smoking
Smoking increases blood carboxyhaemoglobin
Increased carboxyhaemoglobin persists for 12hours after last cigarette
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Diabet 1 Pre and perioperative management depends on severity of disease.
Diet controlled diabetes
No specific precautions.
Check blood sugar and consider Glucose-Potassium-Insulin (GKI) infusion if >12
mmol/l.
Oral hypoglycaemics
Stop long acting sulphonylureas (e.g. chlorpropamide) 48 hours prior to surgery
Short acting agents - omit on morning of operation
Restart when eating normally
Consider GKI infusion for major surgery
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Diabet 2
Insulin dependent diabetes Convert long acting insulins to 8-hourly Actrapid
Place early on operating list
Give GKI infusion until eating normally
GKI infusion
Made up as:
15 u insulin 10 mmol potassium chloride
500 ml 10% glucose
Infused at a rate of 100 ml /hr.
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Icter mecanic Operative morbidity and mortality is increased in patients with obstructive jaundice
due to:
Coagulation disorders
o Reduces the absorption of fat soluble vitamins
o Reduces production of factors II, VII, IX, X
o Disorders can be reversed with Fresh Frozen Plasma or Vitamin K
Reduced wound healing Increased risk of infection
Hepato-renal syndrome
o Acute renal failure in patient with jaundice
o Probably due to systemic endotoxaemia
o Requires adequate hydration and diuretics
o Value of mannitol unproven
Altered drug metabolism
Half life of many analgesics is prolonged (e.g. morphine).
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Insuficienta renala
Chronic renal failure affects multiple organ systems
Effects that need to be considered by both surgeons and
anesthetists includeo Electrolyte disturbances
o Impaired acid-base balance
o Anaemiao Coagulopathy
o Impaired autonomic regulation
o Protection of veins, shunts and fistulae
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Afectiuni hematologice
Pregatirea bolnavilor cu tulburri de coagulare va fi
precedata de o atent investigaie privitoare la cauzele
acestora. Corectarea se face prin transfuzii de snge,
administrare de Vitamina K, trombooite, etc., n raport de
tipul specific de coagulopatie.
Pregatirea bolnavilor anemiciseface prin administrarede transfuzii cu snge total, mas eritrocitar, eventual
fier i Vitamina B12,.
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Explorarea intraoperatorie
obligatorie
trebuie facuta metodic
ofera date complete si precise
a se evita mirajul primei leziuni
Calea de acces
laparoscopielaparotomie
tipuri de incizii
avantaje / dezavantaje
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Diagnosticul intraoperator al modificarilor
intalnite in cavitatea peritoneala
Aderente (periviscerita)
Revarsate peritoneale sange
puroi (peritonite)
bila
ascita
continut intestinal
Tumorimaligne
benigne
inflamatorii
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Explorarea sistematica a organelor abdominale
Stomac Duoden
Pancreas
Ficat
Cai biliare
Splina
Intestin subtire + mezenter
Apendice
Colon si rect
Aparat genital femeiesc
Aparat urinar