Stages of surgical treatment. Preoperative stage
Number of teaching hours – 4.7 (210 min.)
OBJECTIVE OF THE LESSON
Know: principles of special preoperative preparation; principles of classification and pathogenesis of the main postoperative complications
Be able to: prepare for general surgical operations; prevent major postoperative complications
Have an idea about general principles for formulating indications and contraindications for operations; assessment of operational and anesthetic risk
CLASS PLACE
Training room, dressing room, operating room.
PLAN AND TIME CALCULATION
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Time (min.) |
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Indications for surgical treatment | |
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Assessment of surgical and anesthetic risk | |
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General and special preparation for operations | |
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Tasks in the postoperative period | |
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Postoperative complications | |
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Work in the dressing room, operating room | |
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Summing up the lesson, answering questions | |
Surgery is the most important stage in the treatment of a patient. However, in order for the effect of the operation to be maximum, appropriate preoperative preparation and qualified treatment in the postoperative period are necessary. Thus, the main stages of treatment of a surgical patient are:
preoperative preparation;
surgery;
treatment in the postoperative period.
Preoperative period.
The main task of the preoperative period is to minimize the dangers of the operation, prevent possible complications during the operation and in the postoperative period (bleeding, shock, infectious complications, etc.). The goal of preoperative preparation is to reduce the risk of intra- and postoperative complications.
The preoperative period begins from the moment the patient enters the clinic and continues until the start of the operation.
But it is more correct to assume that preoperative preparation begins from the moment of diagnosis requiring surgery and the decision to perform surgical intervention. It ends with the patient being taken to the operating room. Currently, the surgeon does not have the right to begin any complex operation without ascertaining the state of the blood coagulation system, the main metabolic indicators (protein, nitrogenous waste, Hb, red blood cells) in the patient scheduled for the operation and without correcting the identified disorders.
The entire preoperative period is conventionally divided into 2 stages:
diagnostic period;
the actual preoperative preparation, which consists of general preparation of the patient and special preparation, depending on the characteristics of the disease.
Diagnostic stage.
The objectives of the diagnostic stage are to establish an accurate diagnosis of the underlying disease and determine the condition of the main organs and systems of the body.
Making an accurate surgical diagnosis is the key to a successful outcome of the operation. It is an accurate diagnosis indicating the stage, extent of the process and its features that allows you to choose the optimal type and extent of surgical intervention. There can be no trifles here; every feature of the course of the disease must be taken into account. Thus, even before the operation begins, the surgeon knows what difficulties he may encounter during the intervention, and clearly understands the type and features of the upcoming operation.
Example with diagnosis: Acute appendicitis.
The diagnostic period begins with the correct selection of patients in the emergency room and includes a number of stages:
Study of the patient.
Identification of complications and concomitant diseases.
Development of indications and contraindications for surgery, taking into account the legal framework.
Choice of surgical method and anesthesia.
An accurate diagnosis of the disease is primarily necessary in order to decide the urgency of the operation.
If the patient needs emergency surgery, then the preparatory stage should immediately begin, which in emergency operations takes from several minutes to 1-2 hours.
Main indications for emergency surgery, first of all, are bleeding of any etiology and acute purulent diseases.
The doctor must remember that delaying the operation worsens its result every minute. If bleeding continues, the sooner intervention is started and blood loss is stopped, the greater the chance of saving the patient’s life.
At the same time, in some cases (sepsis, peritonitis with severe intoxication and hypotension), it is more advisable to carry out infusion and special therapy for 1-2 hours aimed at improving cardiovascular activity, and only then perform surgery.
The duration of the preoperative period for planned operations can range from 3 days to 3-4 weeks (diffuse toxic goiter with symptoms of thyrotoxicosis).
During the diagnostic period, it is necessary to indicate indications and contraindications for surgery.
Absolute indications for surgery are diseases and conditions that pose a threat to the patient’s life and can only be eliminated surgically:
asphyxia;
bleeding of any etiology;
acute diseases of the abdominal organs (acute appendicitis, acute destructive cholecystitis, perforated gastric and duodenal ulcers, acute intestinal obstruction, strangulated hernia);
abscesses, phlegmon and other acute purulent diseases.
In addition, urgent operations are allocated for cancer patients, without delaying them for more than 7-10 days. These are the following diseases: lung cancer, stomach cancer, breast cancer, colon cancer, pancreatic cancer with obstructive jaundice and others.
Relative indications for surgery are 2 groups of diseases:
I. Diseases that can only be cured surgically, but do not directly threaten the patient’s life (varicose veins, non-strangulated hernia, benign tumors, cholelithiasis, etc.).
P. Diseases, the course of which can, in principle, be carried out both surgically and conservatively (coronary heart disease, obliterating atherosclerosis of the lower extremities, peptic ulcer of the stomach and duodenum).
In these cases, the choice is made on the basis of additional data, taking into account the possible effectiveness of conservative treatment.
Preoperative period – the time from the moment of admission (application) of the patient to a medical institution until the start of the operation.
Purpose of preoperative preparation- studying impaired body functions, creating reserves of functional capabilities of organs and systems to reduce the risk of surgery and minimize the possibility of developing postoperative complications.
Stages of the preoperative period:
1) remote; 2) closest; 3) direct.
Depending on the urgency of the operation, the number of stages may be reduced.
Tasks of the preoperative period:
Establishing a diagnosis.
Carrying out additional and special diagnostic studies
dovaniya.
Determination of indications and contraindications for surgery.
4. Determining the urgency of the operation and its nature
and the choice of anesthesia method (assessment of surgical and anesthetic risk).
16. Preoperative preparation.
17. Prevention of endogenous and exogenous infection.
18. Psychological preparation of patients.
19. Carrying out mandatory and specific preoperative measures
acceptance.
20. Premedication.
10. Transporting the patient to the operating room.
Establishing a diagnosis:
The diagnosis is made based on the patient’s complaints, medical history and life history, clinical manifestations of the disease, laboratory and instrumental research methods.
Examination of the patient:
Depending on the timing of the operation (planned, emergency or urgent), a minimum diagnostic examination must be performed.
At emergency surgery in patients under 40 years of age
General blood analysis
General urine analysis
At emergency surgery in patients over 40 years of age The minimum examination required is:
General blood analysis
General urine analysis
Blood group and Rh factor
Electrocardiogram
Plain chest x-ray
Examination by an anesthesiologist-resuscitator
In addition, according to indications, individual biochemical indicators are taken (for example, blood sugar in a patient with diabetes) and consultations with specialized specialists are carried out (examination by a cardiologist for chronic heart failure). Additional examination according to indications is individual in nature and should be carried out in case of emergency surgical treatment within 2 hours.
At planned surgery for all patients The diagnostic minimum includes:
General blood analysis
General urine analysis
Blood group and Rh factor
Blood for markers of viral hepatitis “B” and “C”
Blood for markers of HIV infection
Blood chemistry
Coagulogram
Electrocardiogram
Plain chest x-ray (or fluorography)
Feces on worm eggs
Examination by a therapist
Examination by a gynecologist (for women)
Dentist examination
Patients admitted for planned hospitalization should be examined as much as possible at the prehospital stage for chronic, sluggish infection (gynecologist, dentist). The scope of instrumental research methods (ultrasound, rectoscopy, colonoscopy, etc.) is decided individually depending on the pathology.
The scope of the diagnostic minimum for urgent surgical intervention should not be less than for emergency surgery. A maximum examination is required in the department, based on medical and economic standards for this pathology.
Determination of indications for emergency, urgent and planned surgery. Vital indications before surgery arise when there is a direct threat to the patient’s life (bleeding, acute diseases of the abdominal organs, purulent-inflammatory diseases, etc.)
Absolute readings to surgery - when failure to perform an operation or its long delay can lead to a condition that threatens the patient’s life. When absolutely indicated, treatment of the disease is possible only surgically (malignant neoplasms, obstructive jaundice, etc.). Long-term delay of surgery in such cases can lead to the development of complications of the disease or irreversible changes in the affected organ and other systems.
Relative readings are prescribed for surgery for diseases that do not pose a threat to the patient’s life (varicose veins of the lower extremities, benign tumors, etc.) For relative indications, temporary refusal of surgery does not cause significant harm to the patient’s health.
In accordance with the given indications of the operation by urgency divided into:
- urgent, or emergency(performed immediately or in the first two hours from the moment the patient enters the surgical hospital),
- urgent(produced within 2 days from the moment of hospitalization),
- planned(performed after a detailed examination of the patient on an outpatient basis).
Stages of surgical treatment. Preoperative stageTreatment of surgical diseases is clearly divided into three stages: the preoperative period, the surgical intervention itself and the postoperative period.
Preoperative period begins from the moment the patient is admitted for inpatient treatment (in elective surgery, some activities can be carried out on an outpatient basis) and ends when the operation itself begins. The preoperative period itself consists of two blocks, which often (especially in emergency surgery) cannot be separated in time. This is a block of diagnostic and a block of preparatory measures. During the diagnostic stage of the preoperative period, the following goals must be achieved: it is necessary to clarify the diagnosis of the underlying disease, to collect information about concomitant diseases as fully as possible, to find out the functional capabilities of the patient’s organs and systems, to determine the tactics of patient management, if surgery is necessary, to clearly formulate the indications for it, to decide with the required volume of the upcoming surgical intervention.
The preparatory block includes the following activities: conservative methods of treatment of the underlying disease, correction of impaired body functions aimed at preparing for surgery, direct preparation for surgery (premedication, shaving, etc.).
In order to most fully fulfill all the requirements of examining a patient at the diagnostic stage, it is necessary to adhere to a certain algorithm. Swipe and pass:
1) preliminary examination (complaints, life history and illness are carefully analyzed, which in chronic patients is traced from the onset of the disease, and in emergency patients - from the beginning of the present attack);
2) a complete physical examination of the patient (palpation, percussion, auscultation according to all requirements);
3) the required minimum of special examination methods: biochemical examination of blood and urine, determination of blood group and Rh factor, blood clotting time and coagulogram, examination of a dentist, ENT doctor, consultation with a therapist, urologist - for men, gynecologist - for women, for all patients over 40 years old - ECG.
During planned treatment, additional studies are also possible (to clarify the presence of concomitant diseases).
Duration of the preoperative period can vary over a very wide range - from several minutes to several months (depending on the urgency of the surgical intervention). In recent years, there has been a tendency to reduce preoperative intervention. Due to the high cost per day of a patient's hospital stay, most of the diagnostic block activities during planned operations are carried out on an outpatient basis. Even a whole area of outpatient surgery is developing, but more on that below. The result of the preoperative period is the writing of a preoperative epicrisis, which should reflect the following main points: justification of the diagnosis, indications for the proposed surgical intervention and its volume, expected pain relief and the patient’s documented consent to the operation.
2. Preparation for surgery
Only the main points of preoperative preparation, which is mandatory for all planned surgical interventions, will be reflected here.
To the totality of these measures, some special methods are added (such as metabolic correction during operations for thyrotoxic goiter, preparation of the large intestine during coloproctological operations).
Preparing the nervous system. The patient is a priori considered to be in a state of neurosis. No matter how strong and strong-willed a person is, he always returns in his thoughts to the upcoming operation. He is tired of previous suffering, excitement is often observed, but more often depression, depression, increased irritability, poor appetite and sleep. To level out the negative aspects of this condition, you can use medication (use of mild anxiolytics and tranquilizers), you must strictly follow all the rules and requirements of deontology, and also properly organize the work of the planned surgical department (patients who have not yet been operated on should be placed separately from those who have already undergone surgery ).
Preparation of the cardiorespiratory system. During normal activity of the cardiovascular system, no special training is required, but breathing correctly is a necessary skill for the patient, especially if surgical intervention on the chest is planned. This will further protect the patient from possible inflammatory complications. If there are any diseases of the respiratory tract, great attention must be paid to this. In the acute stage of a chronic illness or in acute diseases (bronchitis, tracheitis, pneumonia), elective surgery is contraindicated. If necessary, expectorants, medicines, and antibiotic therapy are prescribed. This is of great importance, since hospital-acquired pneumonia can sometimes negate the efforts of the entire surgical team. If the patient has slight functional changes in the activity of the cardiovascular system, their correction is necessary (taking antispasmodics, beta-blockers, drugs that improve the metabolism of the heart muscle). In case of severe organic pathology of the cardiovascular system, treatment by a therapist is necessary until the maximum possible compensation of impaired body functions. Then a comprehensive study is carried out, based on its results a conclusion is made about the possibility of surgery in this case.
A significant percentage is currently allocated to thromboembolic complications. Therefore, all patients need to have their blood coagulation system examined, and those at risk of thromboembolism should be prevented (use heparin and its preparations, as well as aspirin).
High-risk groups – patients with varicose veins, obesity, cancer patients with blood coagulation disorders, who are forced to spend a long time in bed. Often, people who are preparing for a planned operation have anemia (hemoglobin is reduced to 60-70 g/l.). Correction of these disorders is necessary, since regeneration may slow down.
Preparing the digestive system. Sanitation of the oral cavity to eliminate foci of dormant infection, which can lead to stomatitis and mumps. Sanitation of the colon before surgery on it, which includes mechanical cleaning and chemotherapeutic suppression of microflora. Immediately before the operation, a ban on “nothing inside” is imposed, which means depriving the patient of food and water from the very morning on the day of the operation. 12 hours before surgery, if special bowel preparation is not performed, an enema is necessary. They try not to prescribe laxatives. To increase the body's resistance to operational stress, it is necessary to take care of the metabolic protection of the liver and increase its glycogen reserves. For this purpose, infusions of concentrated solutions of glucose with vitamins (ascorbic acid, group B) are used. Methionine, ademetionine and essentiale are also used.
Preparation of the urinary system. Before the operation, a mandatory study of kidney function is carried out, since after the operation they will have to face increased requirements (massive infusion therapy, including the administration of saline and colloid solutions, glucose solutions, drugs and blood components, medications).
Preparing for emergency surgery. Emergency operations are necessary for injuries (soft tissue damage, bone fractures) and acute surgical pathology (appendicitis, cholecystitis, complicated ulcers, strangulated hernias, intestinal obstruction, peritonitis).
Preparing for an emergency operation is fundamentally different from preparing for a planned intervention. Here the surgeon is extremely limited in time. In these operations, the duration of preparation is determined by the tactical algorithm chosen by the operating surgeon. The nature of preparation may also differ for different diseases, but there are still common points. Enemas are usually not done during emergency operations so as not to waste time. The contents of the stomach are removed using a tube. Premedication is carried out as quickly as possible. The surgical field is prepared on the way to the operating room.
Preparing for surgery in older people. It is carried out according to the same principles as the preparation of other categories of patients. It is only necessary to take into account the severity of the concomitant pathology and correct existing disorders with the help of a therapist and anesthesiologist. The volume of the upcoming surgical intervention is selected in accordance with the general somatic condition of the patient and his ability to tolerate the expected pain relief.
Preparing pediatric patients for surgery. In this case, they try to minimize preoperative preparation. All studies that can be performed outside the hospital are carried out on an outpatient basis. It should be remembered that children have a looser bronchial mucosa, which makes them more susceptible to respiratory tract infections (bronchitis, pneumonia).
3. Postoperative period
This period largely determines the patient’s future quality of life, since the timing and completeness of recovery depend on its course (whether it is complicated or uncomplicated). During this period, the patient’s body adapts to the new anatomical and physiological relationships that were created by the operation. This period does not always go smoothly.
By time they are distinguished:
1) early postoperative period (from the end of the operation to 7 days);
2) late postoperative period (after 10 days).
Duration of the postoperative period may vary from patient to patient, even with the same type of surgery. It's all about the individual qualities of the patient's body and the characteristics of its reaction to stress. This is explained by the concept of Selye, who regarded surgical trauma as a severe stress that causes the development of general adaptation syndrome (GAS).
The first stage of OSA, or the anxiety stage (when considering the postoperative period, it is called the catabolic phase), lasts on average (depending on the severity of the surgical intervention) from 1 to 3 days. Stress causes activation of the sympathoadrenal and hypothalamic-pituitary-adrenal systems. This leads to increased secretion of glucocorticoid hormones, which cause many different effects. This is irritation of the central nervous system (hypothermia, hypotension, depression, myoplegia), increased permeability of cell membranes, activation of catabolic processes and (as a consequence) the development of dystrophy, negative nitrogen balance.
Resistance phase or anabolic phase , lasts up to 15 days. During this phase, anabolic processes begin to predominate. Blood pressure and body temperature are normalized, the body's energy and plastic reserves are increased and restored. Protein synthesis is active and reparative processes are activated.
Some authors also distinguish a phase of reverse development, i.e. restoration of body functions disrupted during the catabolic phase. But not everyone shares this point of view. The anabolic phase smoothly transitions into the convalescence phase, or, as it is also called,weight recovery phase .
For a smooth course of the postoperative period, it is extremely important that the first phase does not drag on, since in this case catabolism processes prevail and regeneration is disrupted, which opens the way for complications.
Laboratory diagnosis of such disorders:
1) due to a negative potassium balance, its content in the urine increases and its concentration in the blood decreases;
2) due to the breakdown of protein, there is an increase in nitrogenous bases in the blood;
3) there is a decrease in diuresis.
In the early postoperative period, the patient is usually worried about pain in the surgical area, general weakness, loss of appetite and often nausea, especially after interventions on the abdominal organs, thirst, bloating and flatulence (although more often there is a disturbance in the passage of gases and stools), body temperature can rise to febrile levels (up to 38 ° C).
1. The main tasks of the preoperative period...
Make a diagnosis
Determine indications for surgery
Determine the urgency of the operation
Prepare the patient for surgery
Determine the type of operation
2. Methods of preoperative colon cleansing...
Cleansing enema
– laxatives
Siphon enema
Intestinal lavage
3. The hair in the area of the surgical field is shaved...
– the evening before surgery
On the morning of the operation
- on the operating table
4. Objectives of the diagnostic stage of the preoperative period...
– treatment of concomitant diseases
– creation of functional reserves of internal organs
– prevention of exogenous infection
Clarify the diagnosis and indications for surgery
– find out the functional state of the main organs and systems
5. Correction of metabolic acidosis is mainly achieved by introducing...
Sodium bicarbonate
Glucose with insulin
– Ringer's solution
– polyglucina
– saline solution
6. Objectives of the period of immediate preoperative preparation...
– clarify the diagnosis and indications for surgery
– identify concomitant diseases
Correction of identified disturbances in the functioning of major organs
– determine the scope of the operation
7. Special preoperative preparation measures are...
Bowel preparation during bowel surgery
Parenteral nutrition for esophageal strictures
Correction of sugar in patients with diabetes mellitus
– correction of cardiovascular system disorders during operations on the esophagus
– bowel cleansing for gallbladder surgery under anesthesia
8. To create functional reserves of the body during preparation for surgery, prescribe...
Vitamins
A diet rich in proteins
Glucose with insulin intravenously
– antibiotics
9. General preoperative preparation includes...
Correction of the cardiovascular system in general surgical patients
– detoxification
– sanitation of the bronchi during lung operations
– decompression of the stomach in case of stenosis
Correction of respiratory failure in general surgical patients
10. The preoperative period begins...
– from the moment the patient goes to the clinic for medical help until the diagnosis is made
From the time the patient is admitted to the department until the operation is performed
– from the moment of diagnosis to surgery
– from the moment the patient is admitted to the department until the diagnosis is made
11. Normal hourly diuresis is (ml/hour) ...
12. CVP (central venous pressure) indicators are normal
(mm water column) ...
13. Indicators by which the state of homeostasis is assessed...
ACAS (acid-base state)
Electrolyte composition
14. The presence of dehydration is indicated...
Dry skin
Dryness of the mucous membrane of the tongue
Collapse of superficial veins
Decreased blood pressure
– rapid breathing
15. During emergency operations, preoperative preparation primarily involves correction...
– heart rate
– respiratory failure
Hypovolemia
Dehydration
Mental state of the patient
16. To correct hypovolemia, transfusion is performed...
Poliglyukina
Albumin
Blood plasma
– sodium bicarbonate
Ringer's solution
17. The operation is not performed if the patient is in shock...
Traumatic
– hemorrhagic
Toxic
Burns
18. Surgical tactics for ongoing profuse internal bleeding...
– compensate for blood loss, operate
Emergency surgery to correct hypovolemia
operating table and after surgery
19. Reaching the first mark on the gastric tube indicates that its end is in the stomach...
Cardiac
– antrum
20. During tube gastric lavage before surgery, water is poured into the funnel...
21. Tube gastric emptying before surgery is performed on patients...
Gastric and duodenal ulcers
Stenosis of the stomach and duodenum
– esophageal stenosis
Intestinal obstruction
Terminal stage peritonitis
22. Signs of water and electrolyte retention...
Arterial hypertension
Peripheral edema
Hyperkalemia
Exudative pericarditis
– frequent urination
1. from the moment of illness;
2. from the moment of diagnosis;
3. from the moment of admission to the surgical hospital;
4. -from the moment the indications for surgery are established;
5. from the moment of setting the day of the operation.
Select the main factors that determine the duration of the preoperative period:
1. - the patient’s condition;
2. -severity of concomitant diseases;
3. - the nature of the pathological process;
4. - volume and traumatic nature of the upcoming operation;
5. none of the above.
The stage of immediate preparation for surgery includes?
1. examination of life support systems;
2. -psychological preparation;
3. rehabilitation of chronic foci of infection;
4. -preparation of the gastrointestinal tract and catheterization of the bladder;
5. -premedication.
On the day of surgery for planned surgical intervention, you should perform:
1. the patient must take a hygienic bath or shower as indicated;
2. change underwear and bed linen;
3. transfuse fresh frozen plasma;
4. - shave the hair in the area of the surgical field;
5. rinse the stomach.
What are the goals of the preliminary stage of preoperative preparation?
1. ensure portability of the operation;
2. reduce the likelihood of developing intra- and postoperative complications;
3. speed up the healing process;
4. stabilization of the main parameters of homeostasis;
5. -all of the above.
Operations performed for life-saving reasons are:
1. stomach cancer;
2. lipomatosis;
3. -perforated gastric ulcer;
4. acute cholecystitis;
5. -strangulated ventral postoperative hernia.
The principles of increasing the body’s resistance to surgical trauma are to:
1. standard preoperative preparation;
2. biostimulation of the metabolic functions of the body;
3. adaptation to operational stress;
4. reducing the reactivity of adaptive-regulatory mechanisms by introducing metabolites of stress-releasing and stress-releasing systems;
5. -all of the above.
The early postoperative period begins:
1. after removing the sutures from the surgical wound;
2. after discharge from the hospital;
3. after restoration of working capacity;
4. -the first 2-3 days after surgery;
5. after eliminating early postoperative complications.
The use of an ice pack on a wound in the postoperative period serves the following purposes:
1. preventing the development of infection;
2. prevention of thrombosis and embolism;
3. prevention of divergence of wound edges;
4. -prevention of bleeding from a wound;
5. -reduction of pain.
To prevent thromboembolic complications in the postoperative period, the following should be done:
1. after surgery, examine the state of the blood coagulation system;
2. 2 hours before surgery, administer heparin to patients in the thrombotic group.
5000 units intramuscularly;
3. elastic bandaging of the lower extremities before surgery;
4. active behavior of the patient in bed;
5. -all of the above.
For the prevention of postoperative pneumonia, the following is used:
1. intravenous administration of large quantities of solutions;
2. introduction of proserin;
3. - breathing exercises;
4. -introduction of painkillers;
5. none of the above.
If you experience urinary retention in the postoperative period, you should do the following:
1. cleansing enema;
2. prescribe diuretics;
3. administer 10 ml of 40% methenamine intravenously;
4. - a warm heating pad on the hypogastric area;
5. -catheterization of the bladder.
Which of the noted complications always develop during surgical interventions on the gastrointestinal tract?
1. peritonitis;
2. -paresis of the gastrointestinal tract;
3. -flatulence;
4. oliguria;
5. pneumonia.
In case of paresis of the gastrointestinal tract, the following should be done:
1. blockade according to Roman;
2. hypertensive enema;
3. prescribe the administration of cerucal;
4. administer intravenously a hypertonic sodium chloride solution;
5. -all of the above.
Identify early complications that may develop in a postoperative wound:
1. pain and burning in the wound area;
2. - bleeding from the wound;
3. infiltrate in the wound area;
4. ligature fistula;
5. suppuration of the wound.
An uncomplicated course of the postoperative period is characterized by:
1. duration 1-6 days;
2. positive nitrogen balance;
3. decreased activity of the sympathoadrenal system;
4. restoration of intestinal function;
5. -all of the above.
