Treatment surgical diseases 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 to inpatient treatment(in elective surgery, some activities can be carried out on an outpatient basis) and ends by the time the operation itself begins. The preoperative period itself consists of two blocks, which are often (especially in emergency surgery) cannot be divided by 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 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) required minimum special methods examinations: 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, ECG for all patients over 40 years old.
With planned treatment, it is also possible additional research(in order 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 trend towards a reduction in 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 will be reflected here preoperative preparation, which is mandatory for all planned surgical interventions.
To the totality of these measures, some special methods are added (such as metabolic correction during operations for thyroid toxic goiter, preparation of the large intestine during coloproctological operations).
Preparation of 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 cardiovascular system special training is not required, but breathing correctly is a necessary skill for the patient, especially if surgery is planned on the chest. This will further protect the patient from possible inflammatory complications. If you have any diseases respiratory tract, great attention needs to be paid to this. IN acute stage chronic illness or in case of acute diseases (bronchitis, tracheitis, pneumonia), elective surgery is contraindicated. If necessary, expectorants, medicines, and antibiotic therapy are prescribed. This is given great value, 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). For severe organic pathology The cardiovascular system requires treatment by a therapist until the maximum possible compensation for impaired body functions. Then it is carried out comprehensive study, 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).
Groups increased risk – patients with varicose veins veins, obesity, cancer patients with blood coagulation disorders, forced long time spend 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 are used ( ascorbic acid, group B). Methionine, ademetionine and essentiale are also used.
Preparing urine excretory systems s. Before the operation, a mandatory kidney function test is carried out, since after the operation they will have to face increased demands (massive infusion therapy, including the administration of saline and colloidal 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 the preparation may also differ depending on various diseases, but still there are common points. Enema for emergency operations Usually they don’t do it so as not to waste time. The contents of the stomach are removed using a tube. Premedication is carried out as quickly as possible. Preparation surgical field carried out 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. You just need to take into account the severity 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 different patients even during the same type of operations. 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 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. Normalization occurs blood pressure and body temperature, the body’s energy and plastic reserves increase and are 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 catabolic processes prevail and regeneration is disrupted, which opens the way for complications.
Laboratory diagnosis of such disorders:
1) due to the negative balance of potassium, its content in the urine increases, 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 bothered by pain in the surgical area, general weakness, loss of appetite and often nausea, especially after interventions on organs abdominal cavity, thirst, bloating and flatulence (although more often there is a violation of the passage of gases and stools), body temperature can rise to febrile levels (up to 38 ° C).
4. Complications in the postoperative period. Methods of prevention and correction
IN early postoperative period(especially on the first day) patients need constant dynamic monitoring for the purpose of timely recognition and treatment possible complications, which can occur with any type of surgical intervention. Naturally, after emergency interventions, complications develop more often, since the operation is performed on a patient who has not been fully examined (often in the stage of decompensation of vital functions). Among the complications it should be noted:
1) bleeding (much more often such a complication occurs in the early postoperative period, but can also be observed late period). This is due either to insufficient hemostasis or to the fact that ligatures fly off the vessels. The wound is inspected and the bleeding vessel is ligated;
2) complications from respiratory system(breathing disorders in the post-anesthesia period, atelectasis, pneumonia). Manifested by the appearance of shortness of breath, cyanosis, tachycardia;
3) acute cardiovascular failure (pulmonary edema). Manifested by lack of air, pallor, sweating, acrocyanosis, tachycardia, bloody sputum, swelling of the neck veins. This complication is treated in a critical care complication setting;
4) postoperative paresis gastrointestinal tract. Manifested by nausea, vomiting, hiccups. To prevent this complication, when indicated, intraoperative infiltration of the mesentery is performed with a weak solution of novocaine, and the patient is activated early after surgery. In treatment, measures such as epidural block, perinephric blockade are used, and pharmacological methods include the administration of proserin;
5) development of hepatic-renal failure. Manifested by the development and progression of jaundice, hypotension, tachycardia, drowsiness, lethargy, decreased diuresis, and complaints of nausea and vomiting;
6) thromboembolic complications. Most often develop in patients with a predisposition to the formation of blood clots in the veins lower limbs(oncology patients, patients with obesity, varicose veins, heart failure), with atrial fibrillation after operations on blood vessels and the heart (in the heart and other vessels). To prevent these complications, heparin and its low molecular weight analogues are used according to special regimens.
For prevention of complications The following general activities are of great importance:
1) fight against pain. Extremely important because severe pain is a powerful stress factor. They can lead to a prolongation of the first phase of the postoperative period;
2) function improvement external respiration(breathing exercises);
3) fight against hypoxia and hypovolemia (correction water and electrolyte disturbances with the help of adequate infusion therapy);
4) early activation of the patient.
IN late postoperative period constant dispensary observation for the patient, since complications may arise associated with insufficient adaptation of the body to new anatomical and physiological relationships or an inadequate response of the body to surgical trauma.
5. Examination of a surgical patient
Examination of a surgical patient has its own characteristics. Often patients need emergency assistance therapeutic measures, when the examination is not yet fully completed, but the principle is the following: “Without a diagnosis there is no treatment.” Only from a clearly formulated diagnosis can a tactical algorithm for patient management be derived and the indications for surgery, its nature and scope clearly defined. When examining a patient, one should not forget that the basis of diagnosis is a survey and physical examination of the patient. Special research methods play only a supporting role. Naturally, one should strive to determine the specific disease that the patient has, but one should not forget that some conditions, such as acute abdomen, shock, loss of consciousness, require emergency treatment even before their cause is determined. An important point examination of a surgical patient is to assess operability and operational risk. The examination of the patient begins with clarifying the patient’s complaints (and they should be identified as completely as possible). Next, they begin to collect anamnesis of the disease and life history. Should be paid special attention for the presence of concomitant diseases. Next, they begin a physical examination (inspection, palpation, percussion, auscultation). As a rule, after questioning and physical examination of the patient, it becomes possible to get an idea of the likely diagnosis.
The use of special research methods is determined by what disease is suspected in a given patient. These research methods confirm or refute the initial diagnostic assumption. The patient may require, in addition to the required minimum laboratory research(CBC, OAM, stool tests for worm eggs, blood tests for RW), and biochemical analysis blood, coagulogram, determination of blood group and Rh factor, blood test and urine contents ? -amylase. Also, when examining a surgical patient (especially with purulent pathology), it is important to conduct a complex of microbiological studies, including microscopy, bacteriological examination with determination of the sensitivity of the isolated microflora to antibiotics.
TO instrumental methods research include endoscopic, x-ray, ultrasound, as well as tomography (computer and magnetic resonance).
Endoscopic research methods.
1. Laryngoscopy.
2. Bronchoscopy.
3. Mediastinoscopy.
4. Esophagogastroduodenoscopy.
5. Retrograde cholangiopancreatography (RCPG).
6. Fiber colonoscopy.
7. Sigmoidoscopy.
8. Cystoscopy.
9. Laparoscopy.
10. Thoracoscopy.
X-ray research methods.
1. Minimally invasive:
1) fluoroscopy behind the screen;
2) radiography various areas bodies;
3) tomographic research methods.
2. Invasive (require strict indications because they give a high percentage of complications):
1) angiography;
2) percutaneous transhepatic cholangiography (PTCH);
3) fistulography;
4) excretory urography;
5) intraoperative X-ray methods research.
Ultrasound research methods.
1. Scanning.
2. Echolocation.
3. Dopplerography.
Test control
1. The preoperative period begins with
1) onset of the disease
2) the moment of admission to the surgical hospital
3) establishing a diagnosis
4) the beginning of preparation for the operation
5) bringing the patient to the operating room
*
2. Type of sanitization before planned surgery
1) drying the skin and changing linen
3) complete sanitization
4) sanitization is not performed
5) washing the body with warm water
*
3. The main task of the preoperative period
1) sanitize foci of infection
2) examine the cardiovascular system
3) improve the patient's condition
4) prepare the patient for surgery
5) examine the urinary system
*
4. Time to shave skin before elective surgery
1) one day before surgery
2) the night before
3) in the morning on the day of surgery
4) on operating table
5) 3 hours before surgery
*
5. The surgical field is shaved before emergency surgery.
1) immediately before the operation in the sanitary room
2) on the operating table
3) not produced
4) the day before
5) 2 hours before surgery
*
6. Type of sanitization performed before emergency surgery
1) complete sanitization
2) partial sanitization
3) not implemented
4) only shaving the surgical field
5) wash your body with cold water
*
7. If the patient ate food 40 minutes before emergency surgery, then
1) postpone the operation for a day
2) remove stomach contents through a tube
3) induce vomiting
4) do nothing
5) postpone the operation for 3 hours
8. Before an emergency operation, a cleansing enema is given
1) contraindicated
2) at any time
3) in 1 hour
4) immediately before the operation
5) 3 hours before surgery
*
9. Prescribes premedication to the patient before general anesthesia
1) emergency room doctor
2) anesthesiologist
3) attending physician
4) nurse anesthetist
5) ward nurse
*
10. To prevent postoperative bronchopulmonary complications, the patient is prescribed
1) breathing exercises
2) tracheal intubation
3) a diet rich in protein
4) UHF to the chest
5) antispasmodics
*
11. When preparing a patient for emergency surgery, it is necessary
1) determine the patient’s height
2) give a glass of sweet tea
3) as prescribed by the doctor, remove the contents of the stomach through a tube
4) do a cleansing enema
5) measure body weight
*
12. Complication of the early postoperative period
1) vomiting
2) intestinal eventration
3) bronchopneumonia
4) ligature fistula
5) hernia
*
13. Signs of suppuration postoperative wound
1) paleness of the edges
2) hyperemia, swelling, increased pain
3) soaking the bandage with blood
4) exit of intestinal loops under the skin
5) cold sticky sweat
*
14. If signs of suppuration of a postoperative wound appear, it is necessary
1) apply a dry sterile bandage
2) apply a bandage with ichthyol ointment
3) remove several stitches, drain the wound
4) administer a narcotic analgesic
5) administer antibiotics
*
15. Prevention of postoperative thrombosis consists of
1) adherence to strict bed rest
2) applying cupping massage to the chest
3) use of saline blood substitutes
4) active postoperative management patient, use of anticoagulants
*
16. The main thing in caring for a patient with mechanical ventilation
1) antitussives
2) rehabilitation of the tracheobronchial tree
3) prevention of bedsores
4) feeding through a tube
5) antibacterial therapy
* 17. End date of the postoperative period
1) after eliminating early postoperative complications
2) after discharge from the hospital
3) after healing of the postoperative wound
4) after restoration of working capacity
5) after surgery
*
18. Not used to combat postoperative intestinal paresis
1) hypertensive enema
2) siphon enema
3) intravenous administration of a hypertonic complex
4) administration of proserin solution subcutaneously
5) administration of glucose
*
19. In case of urinary retention after appendectomy, first of all it is necessary
1) cause urination reflexively
2) perform catheterization bladder
3) administer diuretics
4) apply a warm heating pad to the lower abdomen
5) drink plenty of fluids
*
20. To prevent pneumonia in the postoperative period, it is necessary
1) prescribe antitussives
2) ensure strict bed rest
3) perform breathing exercises and massage; putting mustard plasters on the chest
4) ban smoking
5) prescribe euphyllin
*
21. Emergency dressing change after surgery is not required when
1) slight blotting with serous exudate
2) pain at the edges of the wound
3) increased body temperature
4) soaking the bandage in blood
5) itchy skin
3.air in the mediastinal cavity;
4. purulent inflammation of the mediastinal tissue;
5. complication of bullous pulmonary disease
123. K etiological factors purulent mediastinitis includes the following, except:
1. damage to the esophagus;
2. damage to the trachea and bronchi;
3.empyema of the pleura;
4.achalasia of the esophagus.
5. all answers are correct
124. Alveococcosis is characterized by:
1. appositional growth
2.formation of a fibrous capsule
3. formation of daughter and grandchild bubbles
4. infiltrative growth
5. seasonality
125. Intermediate hosts of echinococcus are, except:
1. cattle
2. small cattle
3. person
5. all answers are correct
126. Method of processing the residual cavity according to Akmatov B.A. is:
1. treatment with ozone-oxygen mixture
2. formaldehyde treatment
3. glycerin treatment
4. treatment with furacillin heated to 70C
5. alcohol treatment
127. Intravenous infusion pituitrin for bleeding from varicose veins of the esophagus with portal hypertension is used for the purpose of:
1. Increased blood viscosity
2. Decreased blood activity
3. Reducing pressure in the portal vein system
4. Activation of the process of transition of prothrombin to thrombin
5. Formation of blood clots
128. Many small abscesses in the liver, as a rule, develop:
1. For acute destructive cholecystitis
2. When roundworms crawl into the intrahepatic bile ducts
3. When there is suppuration around foreign body liver
4. For severe purulent cholangitis
5. for liver cirrhosis
129. The main type of surgical intervention for solitary liver abscesses is:
1. Resection of a lobe or segment of the liver
2. Application of biliodigestive anastomosis
3. Opening and draining the abscess
4. Hemihepatectomy
5. Puncture of the abscess from the tank. sowing
130. The following are not typical for Budd-Chiari syndrome:
1. Hepatomegaly
2. Portal hypertension
3. Ascites
4. Facial swelling
5. All answers are correct
131. A probe to stop bleeding from varicose veins of the esophagus can be left:
1. For 6-10 hours
2. For 12-18 hours
3. For 1-8 days
4. For 9-12 days
5. For 24 hours
132. Who most often gets mastitis?
Primipara
multiparous
young girls
menopausal women
pregnant women
2. distribution of visits from city residents
3. implementation of the visit plan
4. average number of visits per resident per year
5. number of residents in the microsite
134. When is late surgical treatment of an infected wound performed?
1. 18-24 hours
2. 24-36 hours
3. 36-48 hours
4. 48-72 hours
2. within a few days
3. within 6-8 days
4. within a few weeks
5. when the level of procalcitonin in the blood increases
142. How long does it take for acute surgical sepsis to develop?
1. within 1-7 days
2. within 1-4 weeks
3. for several months
4. within 2-3 days
5. when S.aureus is detected
143. How long does it take for subacute surgical sepsis to develop?
1. within 1-3 weeks
2. within 1-3 months
3. within 4-5 months
4. within 5-10 days
5. for multiple organ failure
144.The largest location of embologenic occlusions:
1. aortic bifurcation
2. iliac artery
3. femoral artery
4. subclavian artery
5. carotid artery
145. What treatment methods should be chosen for sepsis? a) transfusion of blood components; b) detoxification therapy; c) early activation of the patient; d) antibacterial therapy; e) immunotherapy; e) refusal surgical treatment; g) tube enteral nutrition. choose the correct combination of answers:
1. a, b, c, d, f;
2. b, c, d, e;
3.c, d, d, g;
4. a, b, d, d.
146. What does not indicate the effectiveness of resuscitation measures?
1.presence of a pulse in the carotid artery
2.reduction of cyanosis
3.dry sclera of the eyeballs
4.constriction of pupils
5. increased blood pressure
147. What is tracheal intubation needed for, except?
1.prevention of aspiration
2.improved breathing
3.prevention of asphyxia due to tongue retraction
4. stimulation of the cardiovascular system
5. carrying out intubation anesthesia
148. Specify the main signs of cardiac arrest?
1.absence of pulse in the carotid artery
2.lack of spontaneous breathing
3.narrow pupils
4.lack of consciousness
5. acrocyanosis
149. In the postoperative period in obese patients, the most common problem to be expected is:
1. Fat embolism
2. Cumulation of anesthetic in adipose tissue
3.Pulmonary complications (atelectasis)
4. Fall in blood pressure
4. swelling of the dorsum of the hand
5. all answers are correct
237. After establishing the diagnosis of acute purulent mediastinitis, the following are first of all necessary:
1. massive antibiotic therapy
2. detoxification therapy
3.surgical treatment
4blood transfusion
5. immunotherapy
238. For putrefactive paraproctitis, it is advisable to use:
1. Metrogyl and clindamycin
2. klaforana
3. getamicin
4. cefazolin
5. any of the listed antibiotics
239. Risk factors contributing to the occurrence of nosocomial infection in the preoperative period are:
1. diabetes
2. gout
3. obesity
4. vitamin deficiency
5. previous infectious diseases
240. Damage to the lower laryngeal nerve occurs during operations on the thyroid gland
1. In 3-5% of all cases
2. in 6-10% of all cases
3. in 11-15% of all cases
4. in 16-20% of all cases
241. Parathyroid tetany develops during operations for toxic goiter
1. In 3-5% of all cases
2. in 6-10% of all cases
3. in 11-15% of all cases
4. in 16-20% of all cases
5. in more than 20% of all cases
242. Normal amount parathyroid glands in humans it is generally accepted
1. one pair of glands
2. two pairs of glands
3. three pairs of glands
4. four pairs of glands
5. five pairs of glands
243. Parathyroid glands regulate
1. water-electrolyte metabolism
2. fat metabolism
3. protein metabolism
4. carbohydrate metabolism
5. phosphorus-potassium metabolism
244. Long-term use vitamin D may cause damage
3. skeleton bones
4. Gastrointestinal tract
5. kidney
245. When establishing a diagnosis of Paget’s disease, it is necessary to take into account all of the following, except
1. absence systemic osteoporosis and thickening of bones
2. presence of unchanged phosphorus metabolism
3. onset of the disease in old age
4. high numbers alkaline phosphatase activity
5. the presence of a sharply reduced concentrating ability of the kidneys
246. The clinic of acute blood loss occurs already with a blood loss equal to
247. The main indication for blood transfusion is
1. parenteral nutrition
2. stimulation of hematopoiesis
3. detoxification
4. immunocorrection
5. significant blood loss with anemia
248. When perforated ulcer duodenum more often used
1. gastrectomy
2. various types of vagotomy in combination with economical gastrectomy and other drainage operations
3. suturing + gastroenteroanastomosis
4. Gastric resection to switch off
5. suturing a perforated ulcer
249. Gastrostomy surgery is indicated
1. for inoperable cancer of the body of the stomach
2. for inoperable cancer antrum stomach
3. in all of the above cases
4. in none of the above cases
5. for stenosis of the esophagocardial junction of the stomach caused by a tumor
250. When strangulated hernia in contrast to non-strangulated during surgery, it is necessary
1. first cut the pinching ring
2. you can do both with subsequent plastic surgery of the hernial orifice
3. first dissect the hernial sac
4. perform resection of strangulated formations (intestines, omentum)
5. do laparotomy
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
|
Time (min.) |
|
|
Indications for surgical treatment | |
|
Assessment of surgical and anesthetic risk | |
|
General and special preparation for operations | |
|
Tasks in the postoperative period | |
|
Postoperative complications | |
|
Work in the dressing room, operating room | |
|
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 making a diagnosis requiring surgery and making a 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;
actual preoperative preparation, which consists of general training patient and special training 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. Exactly accurate diagnosis indicating the stage, extent of the process and its features 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, the surgeon, even before the operation begins, 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.
Accurate diagnosis of the disease is primarily necessary in order to decide on the urgency of surgery.
If the patient requires emergency surgery, immediate treatment should be started. preparatory stage, which during 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, 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 abdominal organs ( acute appendicitis, spicy destructive cholecystitis, perforated ulcer of the stomach and duodenum, 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 possible effectiveness conservative treatment.
Preoperative period – this is the time from the moment the patient enters the surgical department until the start of the operation.
Its duration depends on the nature of the disease, the severity of the upcoming operation, its urgency, the presence of concomitant diseases, the state of the person being operated on and the functional state of the cardiovascular, respiratory and excretory systems, as well as the neuropsychic preparedness of the person being operated on.
An important step surgical treatment of the patient is preoperative preparation. Even with a professionally performed operation, if the existing dysfunctions of the organs and systems of the body are not taken into account and their correction is not carried out before the operation, the success of treating the patient is doubtful and the outcome of the operation may be unfavorable. Preparation for surgery begins before the patient is admitted to the hospital, i.e. from the moment the preliminary indications for surgery are determined by a doctor at a clinic or ambulance (psychological preparation of the patient for surgery).
The main tasks of the preoperative period are:
1. Making a topical diagnosis.
2. Determining the urgency of surgical treatment.
3. Preparing the patient for surgery.
Purpose of this period– minimize the risk of the upcoming operation, prevent the possibility of developing postoperative complications and assess the anesthetic risk.
The preoperative period is divided into a diagnostic period, during which the diagnosis is clarified, the condition of organs and systems, the indication for surgery, and the period of preoperative preparation are determined. Its duration depends on the nature of the disease, the presence of concomitant diseases and the functional state of the cardiovascular, respiratory and excretory systems.
To make a topical diagnosis after generally accepted measures, in clinical practice widely used following methods studies: survey radiography, ultrasound indication, endoscopy of organs and cavities, urography, radioisotope methods, computed tomography etc.
Indications for the operation can be: absolute, vital and relative.
Vital indications to surgery arise in such diseases or traumatic injuries, in which delaying the operation for some time leads to the death of the patient. Such operations are performed on an emergency basis, these include the following: pathological conditions:
Continuing bleeding: stomach bleeding, injury to great vessels, rupture of an internal organ (spleen, kidney, liver, etc.)
Acute diseases of the abdominal organs inflammatory in nature(acute appendicitis, thromboembolism, acute intestinal obstruction, strangulated inguinal hernia, etc.) All these diseases are dangerous by the development of peritonitis or organ necrosis due to thromboembolism.
· purulent-inflammatory diseases (abscess, phlegmon, acute osteomyelitis etc.).
Absolute readings to surgery arise in diseases in which failure to perform the operation or a long delay can lead to a condition that threatens the patient’s life. For such indications, the operation is performed urgently a few days after the patient’s admission to the surgical department. Such diseases include obstructive jaundice, pyloric stenosis, lung abscess, etc.
Operation delay for long term may lead to an undesirable outcome or other serious complications.
Relative readings surgery may be for diseases that do not pose a threat to the patient’s life (benign tumors of external localization, uncomplicated hernias, etc.).
After determining the need to perform surgical operation find out contraindications to its implementation: cardiac, respiratory and vascular insufficiency, myocardial infarction, stroke, hepatic-renal failure, severe violations metabolism, severe anemia. All these changes in organs, according to the severity and volume of the upcoming operation, are assessed individually for each patient. In this case, it is necessary to involve appropriate specialists (therapist, neurologist, etc.).
When performing an operation on vital signs, when the patient’s time is limited in time, then the severity of the patient’s condition and further preparation for surgery should be carried out jointly with the anesthesiologist-resuscitator and therapist.
At absolute readings Preparation for surgery is aimed at restoring the impaired functions of certain organs.
At relative indications to surgery and the presence of concomitant diseases that increase the risk of surgery, such operations are postponed until treatment by a specialist in the concomitant disease.
When preparing a patient for surgery, special attention should be paid to the condition of those organs and systems to which increased demands are placed during surgery: (nervous system, cardiovascular and hematopoietic system, respiratory system, gastrointestinal tract, liver, kidneys, skin.) . Therefore, the basis of preoperative preparation of the patient is careful consideration possible dangers operations and carrying out measures aimed at their prevention, the implementation of which requires the following:
1. Make a topical diagnosis and determine the method of surgery.
2. Clarify the indications and identify contraindications for the operation and choose a method of pain relief.
3. Determine the condition and degree of function of the patient’s organs and systems.
4. Identify existing complications and concomitant diseases.
5. Increase the immunobiological strength of the body, create functional reserves of organs and systems.
All this is resolved with strict adherence the severity of the upcoming surgical intervention, the nature of his disease and accounting individual characteristics sick.
The preoperative period is the period from the moment the patient is admitted to the hospital until the start of the operation.
PREOPERATIVE PREPARATION OF PATIENTS
LECTURE No. 9
Most patients who are admitted to the surgical department undergo surgery. From the moment of admission to the hospital, the preoperative period begins, during which efforts are aimed at reducing the risk of surgery and preventing complications that may arise during and after it.
Goals of preoperative preparation:
o Ensure tolerance of surgical trauma;
o Reduce the likelihood of developing intra- and postoperative complications;
o Speed up the healing process.
Objectives of preoperative preparation:
· Stabilization of the main parameters of homeostasis, if necessary, primary preoperative detoxification;
· Preparation of the respiratory tract and gastrointestinal tract;
· Preparation of the surgical field;
· Emptying the bladder;
· Premedication.
There are two stages in the preoperative period:
Ø Diagnostic or stage of preliminary preparation for surgery (from the moment the patient is admitted to the hospital until the day of surgery is scheduled);
Ø Stage of immediate preparation (from the moment of setting the day of the operation to the start of the operation).
The preliminary preparation stage includes:
· Establishment/clarification of diagnosis;
· Examination of the body's life support systems;
· Determination of concomitant diseases;
· Risk assessment of surgical intervention;
· Correction of identified dysfunctions of organs and systems, sanitation of chronic foci of infection, stimulation of the body's resistance mechanisms are carried out.
The moral state of patients admitted for surgery differs significantly from the state of patients hospitalized for conservative treatment, since surgery is a major physical and mental trauma. It is important that from the first minutes of admission, from the emergency department to the operating room, the patient feels the precise work of the medical staff. He looks closely and listens to everything around him, is constantly in a state of tension, turns primarily to middle and junior medical personnel, and seeks their support. Calm behavior, gentle treatment, and a calming word spoken at the right time are extremely important. The indifferent attitude of the nurse, the staff’s negotiations about personal, irrelevant things in the presence of the patient, the inattentive attitude to requests and complaints give the patient a reason to doubt all further activities and put him on guard. Talk by medical personnel about the poor outcome of the operation, death, etc. has a negative effect. Medical staff with all his behavior he must inspire the patient’s favor and trust. The patient’s recovery depends not only on a well-technically performed operation, but no less on carefully conducted preoperative preparation; in some cases, caring for a surgical patient decides his fate. Caring staff not only must know how to carry out the doctor’s prescription, but must understand why this prescription was made, how it is useful for the patient, and what harm can be caused to the patient by failure to comply with certain doctor’s instructions. Only one can prepare a patient well for surgery who will carry out the doctor’s orders not automatically, but consciously, and understand the essence of the activities being carried out.
Preoperative preparation of patients consists of a set of measures. In some cases they are reduced to a minimum (in case of emergency and emergency operations), and during planned operations should be carried out more carefully.
Activities carried out to prepare patients for surgery can be divided into - - general, i.e. mandatory before each operation,
· Hygienic bath or shower;
· Change of underwear and bed linen,
· Shaving hair in the surgical area (strictly on the day of surgery, but no more than 6 hours between shaving and surgery),
Cleansing enema
· Emptying the bladder.
- special, special ones that need to be carried out only in preparation for certain operations.
Specific events include:
o Gastric lavage (operations upper sections Gastrointestinal tract)
o Siphon enema (colon surgery, etc.)
TO basic research planned patients include:
· measuring the patient's height and weight,
determination of blood pressure,
· clinical analysis of blood and urine,
· biochemical blood test,
· coagulogram,
· blood test for hepatitis markers, RW, HIV.
determination of blood group and Rh factor,
X-ray/fluorography of organs chest,
Ultrasound of the abdominal organs,
· Examination by an ENT doctor or dentist – sanitation of foci of chronic infection.
· examination of stool for worm eggs.
At emergency operations Premedication (injection of a solution of morphine or promedol), shaving the surgical field and emptying the stomach of its contents are sufficient. In patients with severe injuries, it is necessary to begin immediately anti-shock measures(pain relief, blockades, blood transfusions and anti-shock fluids). Before surgery for peritonitis, intestinal obstruction, emergency measures to combat dehydration, detoxification therapy, correction of salt and electrolyte balance. These measures should begin from the moment the patient is admitted and should not cause a delay in the operation.
When preparing a patient for a planned operation, there should be diagnosis clarified, concomitant diseases have been identified that can complicate and sometimes make the operation impossible. It is necessary to identify foci of endogenous infection and, if possible, sanitize them. In the preoperative period, the function of the lungs and heart is examined, especially in elderly patients. Weakened patients require preoperative transfusions of protein drugs and blood, as well as combating dehydration. Much attention should be paid to preparing the patient's nervous system before surgery.
The risk of surgical intervention is based on taking into account:
ü Age;
ü Functional status vital important systems body;
ü The severity of the main and concomitant diseases;
ü Urgency and volume of the operation.
Operational risk criteria:
q Risk I degree– a somatically healthy patient undergoing a minor planned surgical intervention (opening of abscesses, diagnostic procedures).
q Risk II A degree– somatically healthy patients undergoing more complex planned surgical intervention (appendectomy, cholecystectomy, surgery to remove benign tumors etc.)
q Risk III B degree– patients with relative compensation of life support systems and functions internal organs undergoing minor elective operations listed in the category “risk of degree I”.
q Risk III A degree– patients with full compensation of life support systems and functions of internal organs, undergoing complex, extensive interventions (gastric resection, gastrectomy, operations on the colon and rectum, etc.)
q Risk III B degree– patients with subcompensation of life support systems and functions of internal organs, exposed to minor surgical interventions.
q Risk IV degree– Patients with a combination of deep, general somatic disorders (acute or chronic, caused, for example, by myocardial infarction, trauma, shock, massive bleeding, diffuse peritonitis, endogenous intoxication, renal and liver failure, etc.) undergoing major or extensive surgical interventions, which in most cases with the listed pathology are performed on an emergency basis or even for vital reasons.
q Risk V degree(highlighted in separate degree some clinics, but not accepted into the mandatory classification) - patients with decompensation of vital support organs and functions of internal organs, with surgical intervention where there is a high risk fatal outcome on the operating table, and in the early postoperative period.
