Riscul Anestezico Chirurgical Pregatirea pacientului pentru operatie Explorarea intraoperatorie

Dr. Daha Claudiu

Riscul Anestezico Chirurgical

Stabilirea tacticii operatorii se va face in raport de riscul operator al bolnavului. Stabilirea riscului operator si anestezic se face in functie urmatorii factori:

vrst,

tare organice,
complexitatea urgena tipul

actului operator,

anesteziei

Riscul anestezico chirurgical < riscul evolutiei spontane a bolii (postulatul lui Hamburger) Desi are o valoare relativ evaluarea RAC este obligatorie

Schema Adriani
I Bolnav tnr sau de vrst mijlocie, fr tare organice la care se face o intervenie chirurgical mic sau mijlocie ; II Bolnav cu boli compensate sau care nu pune probleme deosebite de reechilibrare, la care se va practica o operaie major ; III Bolnav cu tare organice avansate care nu snt mortale imediat i care va suferi o intervenie major ; IV Bolnav decompensat care va fi supus unei intervenii majore ; V Operaii de urgen la bolnavii din grupele I i II ; VI Operaii de urgen la bolnavii din grupele III si IV.

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.

Clasificarea ASA
ASA Grade Definition
Normal healthy individual
Mild systemic disease that does not limit activity Severe systemic disease that limits activity but is not incapacitating Incapacitating systemic disease which is constantly life-threatening Moribund, not expected to survive 24 hours with or without surgery

Mortality (%)
0.05
0.4 4.5 25 50

I
II III IV V

Investigatii preoperatorii

De rutina:
HLG

+ VSH Biochimie ECG RX pulmonar

Investigatii preoperatorii suplimentare

Sunt necesare daca:

examenul

clinic deceleaza elemente patologice unei patologii asociate

probabilitatea existentei

asimptomatice
chirurgie majora

-interventii complexe

Pregatirea pacientului pentru operatie

Operaie + anestezie = agresiune asupra organismului totalitatea gesturilor ntreprinse pentru a diminua efectele actului operator, ale anesteziei i ale traumei psihice survenite. Pregtirea preoperatorie:
msuri

de ordin general ce sunt aplicate tuturor pacienilor msuri particulare, necesare unei anumite categorii de bolnavi

Masuri cu caracter general

Pregatirea psihica
Igiena bolnavului Golirea intestinului

Pregatirea psihica

Asigurarea confortului (rezerva curat, luminat, ferita de zgomote, nclzit n jur de 2022C, aerisita, etc) Cucerirea ncrederii bolnavului de ctre personalul medicosanitar, 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.

Igiena bolnavului

Imbaierea i schimbarea lenjeriei este obligatorie Pregatirea tegumentelor In dimineaa interveniei

radere

n regiunea unde se va efectua intervenia chirurgical, cu detergent i

spalarea iodare,

eventual pansament steril

Asanarea focarelor septice (dentare, cutanate, etc)

Golirea intestinului

Regim hidric cu 24h inainte

Oprirea lichidelor cu minim 6h inainte

Laxative cu 24h inainte

Clisma evacuatorie (seara dinaintea operatiei)

Pregtirea aparatului sau organului

Aparat respirator
aspirare

secretii bronsice mucolitice, antibiotice intubare selectiva cu sonda Carlins

Esofag Stomac
aspiratie eventual

spalatura

Colon
dieta

purgative
clisme

(Fortrans, Manitol, ulei de ricin)

antibiotice

Aparat genital - spalatura vaginala cu antiseptice

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

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

Denutriti, hipoproteici

bolnav cu pierdere ponderala, masa musculara i esutul grsos diminuat foarte mult, palid, edeme i tulburri trofice ale tegumentelor, fora fizica i intelectual sczute mult. Reechilibrarea trebuie nceput 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 mai ales 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

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 risk o 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

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%

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 or poorly 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

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 Spirometry o Arterial blood gases Upper respiratory tract infections increase the risk postoperative chest complications Elective surgery should be deferred for 2-4 weeks

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 12 hours after last cigarette

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

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.

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).

Insuficienta renala

Chronic renal failure affects multiple organ systems Effects that need to be considered by both surgeons and anesthetists include

o Electrolyte disturbances
o Impaired acid-base balance o Anaemia o Coagulopathy o Impaired autonomic regulation o Protection of veins, shunts and fistulae

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 anemici se face prin administrare de transfuzii cu snge total, mas eritrocitar, eventual fier i Vitamina B12,.

Explorarea intraoperatorie

obligatorie trebuie facuta metodic ofera date complete si precise a se evita mirajul primei leziuni Calea de acces
laparoscopie laparotomie
tipuri

de incizii

avantaje

/ dezavantaje

Diagnosticul intraoperator al modificarilor intalnite in cavitatea peritoneala

Aderente (periviscerita) Revarsate peritoneale

sange puroi

(peritonite)

bila
ascita continut

intestinal

Tumori
maligne benigne

inflamatorii

Explorarea sistematica a organelor abdominale

Stomac Duoden Pancreas Ficat Cai biliare Splina Intestin subtire + mezenter Apendice Colon si rect Aparat genital femeiesc Aparat urinar