lp rac + pregatire preop

7/30/2019 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

lp rac + pregatire preop

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