‫קבלה של חולה בכירורגיה‬
‫יונתן אברהם דמה‬
‫סיבת הפניה‬
‫מחלה נוכחית‬
‫הבעיה‪ ,‬זמן‬
‫תלונות נלוות‪ :‬מעי‪ ,‬שד‪...‬‬
‫בדיקות לבירור‪ :‬אנדוסקופיה‪ ,‬קולונוסקופיה ‪U/S, CT,‬‬
‫ממוגרפיה‪.MRI ,‬‬
‫גורמי סיכון‪ :‬סיפור משפחתי‪ ,‬שד‪...‬‬
‫רקע‬
‫סוגי ניתוחים‬
‫‪ ‬דחוף (‪ - )urgent‬מיידי או מוות‪.‬‬
‫‪ :Emergent ‬יש לבצעו תוך ‪ 24‬שעות‪.‬‬
‫‪ ‬אלקטיבי‪ :‬יש זמן להכנת החולה‪.‬‬
‫‪ ‬מג'ורי (קשים‪ ,‬נרחבים וממושכים ‪-‬השתלות כבד‪ ,‬לבלב‪ ,‬כריתות‬
‫וכו')‪.‬‬
‫‪ ‬רגיל (רוב הניתוחים)‪.‬‬
‫‪ ‬מינורי (למשל הסרת לזיות עוריות בהרדמה מקומית)‪.‬‬
‫רקע‬
Age
Nutritional Status
Obesity
Cardiovascular
Cerebro-vascular
Pulmonary
Renal
Hepatobiliary
Endocrine
Hematologic
ASA Classification
I—Normal healthy patient
II—Patient with mild systemic disease
III—Patient with severe systemic disease that limits activity
but is not incapacitating
IV—Patient who has incapacitating disease that is a
constant threat to life
V—Moribund patient not expected to survive 24 hours with
or without an operation
Significant independent predictor of mortality.[
Age
Age has been reported as an independent risk factor
for postoperative mortality.
Predicting and preventing postoperative delirium
Patients with three or more of the following have a
50% risk for postoperative delirium:







70 years or older;
self-reported alcohol abuse;
poor cognitive status;
poor functional status;
markedly abnormal preoperative serum sodium, potassium,
or glucose level;
noncardiac thoracic surgery;
and aortic aneurysm surgery.
Post operative delirium
If delirium does occur, metabolic and infectious
causes need to be investigated before labeling the
event as sundowning.
Nutritional Status
 Evaluation of the patient's nutritional status is part
of the preoperative evaluation.
 A history of weight loss greater than 10% of body
weight over a 6-month period or 5% over a month is
significant.
Degree of malnutrition
 temporal wasting,
 cachexia,
 poor dentition,
 ascites,
 peripheral edema
Serum markers
 Albumin (half-life, 14-18 days),
 Transferrin (half-life, 7 days),
 Prealbumin (half-life, 3-5 days)
TPN
 Patients with severe malnutrition appear to
benefit most from preoperative parenteral nutrition.
 The majority of studies show a reduction in the rate
of postoperative complications from approximately
40% to 30%.
Obesity
The perioperative mortality rate is significantly
increased in patients with clinically severe obesity:
body mass index [BMI] >40 kg/m2 or BMI >35
kg/m2 with significant comorbid conditions.
Severe obesity
Clinically severe obesity is associated with a higher
frequency:





essential hypertension
pulmonary hypertension
left ventricular hypertrophy
congestive heart failure
ischemic heart disease
:‫לפי הספר‬
Patients with no or one of these risk factors receive a
β-blocker preoperatively for cardio-protection.
Patients with two or more risk factors undergo
noninvasive cardiac testing preoperatively.
Obesity
 Obesity is also a risk factor for postoperative
wound infection.
 The rate of wound infections is much lower with
laparoscopic surgery in this group, which could
have a bearing on selection of the operative
approach.
Obesity
Obesity is an independent risk factor for DVT and
PE.
appropriate prophylaxis is instituted in these patients.
CLEXAN
Cardiovascular disease
- leading cause of death in the industrialized world,
- its contribution to perioperative mortality during
noncardiac surgery is significant.
Cardiovascular disease
Of the 27 million patients undergoing surgery in the
United States every year, 8 million, or nearly 30%,
have significant coronary artery disease or other
cardiac comorbid conditions.
One million of these patients will experience
perioperative cardiac complications, with substantial
morbidity, mortality, and cost.
Revised Cardiac Risk Index
1.
Ischemic heart disease
1
2.
Congestive heart failure
1
3.
Cerebral vascular disease
1
4.
High-risk surgery
1
5.
Preoperative insulin treatment of diabetes
1
6.
Preoperative creatinine >2 mg/dL
1
Each increment in points increases the risk for postoperative
myocardial morbidity
‫‪Revised Cardiac Risk Index‬‬
‫סיכון לסיבוך קרדיאלי מאג'ורי‬
‫‪ 0 ‬גורמי סיכון – ‪0.4%‬‬
‫‪ 1 ‬גורמי סיכון ‪0.9%‬‬
‫‪ 2 ‬גורמי סיכון ‪7%‬‬
‫‪ 3 ‬ומעלה ג"ס – ‪11%‬‬
Cardiac Tests
1.
2.
3.
4.
5.
patient's functional capacity, which is estimated by
obtaining a history of the patient's daily activities. 2
flight of stairs.
Standard exercise stress test
Echography
Pharmacologic stress testing with dipyridamole
Angiography
IHD
Patients who have undergone a percutaneous coronary
intervention with stenting need to have elective
noncardiac procedures delayed for 4 to 6
weeks.
General recommendations are to wait 4 to 6 weeks
after MI to perform elective surgery.
‫‪IHD‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫אנגינה יציבה – הקשר לסיבוכים לא ודאי – יש בכל זאת לבצע בירור‪.‬‬
‫אנגינה לא יציבה (במנוחה או פעילות מינמלית) – רצוי לדחות ניתוחים אלקטיביים‬
‫עד להמשך הבירור הלבבי‪.‬‬
‫אוטם לאחרונה (ב ‪ 6‬חודשים אחרונים) – יש ‪ 11-16%‬סיכון לאוטם חוזר ב ‪3-6‬‬
‫חודשים אחרי הניתוח‪ ,‬וגם נשאר גבוה אחרי ‪ 6‬חודשים‪ 4-5%( .‬לעומת ‪0.1%‬‬
‫באנשים ללא היסטוריה של ‪.)MI‬‬
B-Blokers
Perioperative risk for cardiovascular morbidity
and mortality was decreased by 67% and 55%,
respectively, in ACC/AHA-defined medium- to highrisk patients receiving β-blockers in the
perioperative period versus those receiving placebo.
‫‪VHD‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪ AS‬מגביר סיכון פי ‪.14‬‬
‫בכל אוושה מסוג ‪ –Ejection‬נעשה ‪ Echo‬לפני ניתוח‪.‬‬
‫יש לברר תלונות של קוצ"נ במאמץ‪ ,‬כאב בחזה וסינקופה‪.‬‬
‫בכל מחלה מסתמית (פרט ל ‪ MVP‬ללא אוושה) יש צורך‬
‫באנטיביוטיקה כמניעה לאנדוקרדיטיס בפרוצדורות‪.‬‬
‫מחלה צרברו‪-‬וסקולרית‬
‫‪ ‬שבץ סביב ניתוחי הוא סיבוך נדיר יחסית‪ :‬פחות מ ‪ ,1%‬וכ ‪2-5%‬‬
‫מחולי לב‪.‬‬
‫‪ ‬מעל ‪ 80%‬מופיעים אחרי הניתוח – ולרוב קורים מירידה בל"ד‬
‫ואמבוליות קרדיוגניות מפרפור פרוזדורים‪.‬‬
‫‪ ‬המתח הניתוחי החריף עלול לגרום לסימנים פוקאליים של שבץ קודם‬
‫לחזור ולהופיע ולחקות כך איסכמיה חריפה‪.‬‬
‫מחלה צרברו‪-‬וסקולרית‬
‫גורמי סיכון‪:‬‬
‫‪‬גיל‪,‬‬
‫‪‬יתר ל"ד‪,‬‬
‫‪‬מחלת לב קורונרית‪,‬‬
‫‪‬סכרת‬
‫‪‬אישון‪.‬‬
‫אוושה אסימפטומטת בקרוטיד‬
‫‪ ‬יחסית שכיחה ‪ -‬קורה ב ‪ 14%‬מהמנותחים מעל גיל ‪.55‬‬
‫‪ ‬בפחות מ‪ % 50‬זה משקף בעיה המודינמית משמעותית‪.‬‬
‫‪ ‬לא הודגמה עלייה בסיכון לשבץ בניתוחים שאינם בלב – אך סביר‬
‫לעשות דופלר קרוטידים בחולים אלו לפני פרוצדורות ניתוחיות‬
‫משמעותיות‪.‬‬
‫חולים עם ‪ TIA‬לאחרונה‬
‫בסיכון מוגבר לשבץ ולכן צריכים לעבור הערכה נוירולוגית לפני ניתוח‪:‬‬
‫‪ CT ‬ראש‪,‬‬
‫‪ ‬אקו‪,‬‬
‫‪ ‬דופלר קרוטידים‪.‬‬
‫אם אצלם ידועה הצרות סימפטומטית בקרוטיד – הם יצטרכו לעבור‬
‫‪ Endarterectomy‬לפני ניתוח אלקטיבי כללי‪.‬‬
‫שבץ לאחרונה‬
‫יש לדחות את ניתוח אלקטיבי לפחות ב‪ 6‬שבועות‪.‬‬
Pulmonary
Consider assessment of pulmonary function:
all lung resection cases,
thoracic procedures requiring single-lung ventilation,
major abdominal and thoracic cases in patients who
are older than 60 years,
have significant underlying medical disease,
smoke,
pulmonary symptomatology.
pulmonary complication
 pneumonia
 respiratory failure
 Need of tracheostomy
Adults with an FEV1 of less than 0.8 L/sec, or
30% of predicted, have a high risk for complications
and postoperative pulmonary insufficiency.
Risk factor of pulmonary complications











age,
dependent functional status,
weight loss, lower albumin level,
Obesity, Obstructive sleep apnea
previous stroke,
congestive heart failure,
renal failure,
chronic obstructive pulmonary disease, smoking,
preoperative sputum production, pneumonia, dyspnea,
chronic steroid use,
blood transfusion
Preoperative interventionS
 smoking cessation (>2 months before the planned
procedure),
 bronchodilator therapy,
 antibiotic therapy for preexisting infection,
 pretreatment of asthmatic patients with steroids.
Perioperative strategies
 epidural anesthesia,
 vigorous pulmonary toilet and rehabilitation,
 bronchodilator therapy. Aerovent, Ventolin
Renal
 Approximately 5% of the adult population
have some degree of renal dysfunction and cause
additional morbidity in the perioperative period.
 a preoperative creatinine level of 2.0 mg/dL or
higher is an independent risk factor for cardiac
complications.
Renal
 history and physical examination: particular
questioning about previous MI and symptoms
consistent with ischemic heart disease.
 The cardiovascular examination seeks signs of
fluid overload.
Anemia in CRF
Anemia may range from mild and asymptomatic to
that associated with fatigue, low exercise
tolerance, and exertional angina.
Such anemia can be treated with erythropoietin
preoperatively or perioperatively.
Thrombocytopathy
Because the platelet dysfunction associated with
uremia is often a qualitative one, platelet counts are
usually normal.
Dialysis
Patients with chronic end-stage renal disease undergo
dialysis before surgery to optimize their volume
status and control the potassium level.
Prevention of secondary renal insults
 avoidance of nephrotoxic agents
 maintenance of adequate intravascular volume
 nonsteroidal agents are avoided
Hepatobiliary
 A history of any exposure to blood and blood
products or exposure to hepatotoxic agents.
 Patients need to be questioned about when the
diagnosis was made and what activity led to the
infection.
 it is important to obtain this information in
case an operative team member is injured
during the planned surgical procedure.
Symptoms
 pruritus,
 fatigability,
 excessive bleeding,
 abdominal distention,
 weight gain.
Evidence of hepatic dysfunction on physical
examination
 Jaundice and scleral icterus may be evident with








serum bilirubin levels higher than 3 mg/dL.
spider angiomas,
caput medusae,
palmar erythema,
clubbing
ascites: Abdominal distention, evidence of fluid shift
Encephalopathy
Asterixis
Muscle wasting or cachexia
liver function tests
 hepatocellular enzymes: acute or chronic hepatitis.
 HAV, HBV, HCV
 Alcoholic hepatitis (AST/ALT greater than 2).
 hepatic synthetic function: serum albumin,
prothrombin, and fibrinogen.
Child-Pugh Scoring System
POINTS
1
2
3
Encephalopathy
None
Stage I or II
Stage III or IV
Ascites
Absent
Slight (controlled
with diuretics)
Moderate despite
diuretic treatment
Bilirubin
(mg/dL)
<2
2-3
>3
Albumin (g/L)
>3.5
2.8-3.5
<2.8
PT (prolonged
seconds)
<4
4-6
>6
INR
<1.7
1.7-2.3
>2.3
Class A = 5-6 points; Class B = 7-9 points; Class C = 1015 points.
 initially applied to predict mortality in cirrhotic
patients undergoing portacaval shunt procedures,
 it has been shown to correlate with mortality in
cirrhotic patients undergoing a wider spectrum of
procedures.
 Mortality rate Child A-10%, B-31%, and C-76%
during abdominal operations.
Endocrine
 diabetes mellitus,
 hyperthyroidism or hypothyroidism,
 adrenal insufficiency
Diabetes Mellitus
Presence of diabetic complications:
 cardiac disease,
 circulatory abnormalities,
 retinopathy,
 neuropathy,
 nephropathy.
Preoperative testing
 fasting and postprandial glucose
 hemoglobin A1c levels
 Serum electrolyte
 blood urea nitrogen, and creatinine levels
 Urinalysis: proteinuria.
Neuropathy
The existence of neuropathy in diabetics may be
accompanied by cardiac autonomic neuropathy,
which increases the risk for cardiorespiratory
instability in the perioperative period.
DM Treatment
The adequacy of perioperative glycemic control has an
impact on wound healing and the risk for
surgical site infection.
Discontinue:
 long-acting sulfonylureas such as chlorpropamide
and glyburide because of the risk for hypoglycemia;
 metformin because of its association with
lacticacidosis in the setting of renal insufficiency.
Treatment
 a shorter-acting agent or sliding-scale insulin
coverage
 Frequent assessments of glucose levels are continued
through the postoperative period
 maintain the perioperative glucose level between 80
and 150 mg/dL.
Postoperative cardiac events can occur with unusual
manifestations in these patients.
Although chest pain needs to be evaluated with ECG
and serum troponin levels, this same evaluation
may need to be done for new-onset dyspnea, blood
pressure alterations, or a decrease in urine
output.
Thyroid disease
Hyperthroidism
Evidence of hyperthyroidism is addressed
preoperatively and surgery deferred until a
euthyroid state is achieved.
 antithyroid medication such as propylthiouracil or
methimazole is gived
 β-blockers or digoxin are also continued
Hypothyroidism
Hypothyroidism generally do not require
preoperative treatment.
Severe hypothyroidism
Severe hypothyroidism can be associated with:
 myocardial dysfunction,
 coagulation abnormality,
 electrolyte imbalance,
 hypoglycemia.
Severe hypothyroidism needs to be corrected before
elective operations.
Steroid use
A patient with a history of steroid use may require
supplementation for a presumed abnormal
adrenal response to perioperative stress.
Steroid use
 Patients who have taken more than 5 mg of
prednisone (or equivalent) per day for more
than 3 weeks within the past year are
considered at risk when undergoing major surgery.
 Lower doses of steroid or minor procedures are not
generally associated with adrenal suppression.
Steroid use
Minor operations such as hernia repair under local
anesthesia may not require any additional
steroid
The adequacy of the hypothalamic-pituitary response
to adrenocorticotropic hormone (ACTH) can be tested
in any patient who may have some degree of
suppression secondary to chronic or intermittent
steroid use:
low-dose ACTH stimulation test
Steroid use
 Moderate operations such as open cholecystectomy
or lower extremity revascularization: 50 to 75
mg/day of hydrocortisone equivalent for 1 or 2
days.
 Major operations such as colectomy or cardiac
surgery are covered with 100 to 150 mg/day of
hydrocortisone equivalent for 2 to 3 days.
Hematologic
 anemia,
 inherited or acquired coagulopathy,
 hypercoagulable state.
Anemia evaluation
 CBC,
 reticulocyte count,
 serum iron,
 total iron-binding capacity,
 ferritin,
 vitamin B12,
 folate
Blood transfusion
patients with normovolemic anemia without
significant cardiac risk or anticipated blood loss can be
managed safely without transfusion.
most healthy patients tolerating hemoglobin
levels of 6 or 7 g/dL.
Coagulopathy
Coagulopathy may result from inherited or acquired
platelet or factor disorders or may be associated with organ
dysfunction or medications
 personal or family history of abnormal bleeding.
 history of liver or kidney dysfunction or recent common
bile duct obstruction
 use of anticoagulants, salicylates, nonsteroidal antiinflammatory drugs (NSAIDs), and antiplatelet drugs are
noted.
 Physical examination may reveal bruising, petechiae, or
signs of liver dysfunction.
Platelets
 qualitative or quantitative defects as a result of
immune-related disease, infection, drugs, or liver or
kidney dysfunction.
 Qualitative defects may respond to medical
management of the underlying disease
process,
 quantitative defects may require platelet
transfusion when counts are less than 50,000 in a
patient at risk for bleeding.
anticoagulation therapy
anticoagulation therapy usually require preoperative
reversal of the anticoagulant effect. FFP, VIT K
In patients taking warfarin, the drug is withheld for
four scheduled doses preoperatively to allow the
international normalized ratio (INR) to fall to the
range of 1.5 or less (assuming that the patient is
maintained at an INR of 2.0-3.0).
 Patients with a recent history of venous
thromboembolism or acute arterial embolism
frequently require perioperative IV heparinization
because of an increased risk for recurrent events in
the perioperative period.
 Patients taking anticoagulants for less than 2 weeks
for pulmonary embolism (PE) or proximal
DVT are considered for inferior vena cava filter
placement before surgery.
risk for venous thromboembolism
 Patients are questioned to elicit any personal or
family history suggestive of a hypercoagulable state.
Ex: aborption
 Levels of protein C, protein S, antithrombin III, and
antiphospholipid antibody can be obtained.
Risk factor stratification
 age,
 type of surgical procedure (hip or knee arthroplasty, hip










fracture surgery; major trauma; spinal cord injury),
previous thromboembolism,
cancer,
obesity,
varicose veins,
cardiac dysfunction,
indwelling central venous catheters,
inflammatory bowel disease,
nephrotic syndrome,
pregnancy,
estrogen or tamoxifen use.
‫בדיקות‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫ספירה – אובדן דם משמעותי‪ ,‬מחלה כרונית‬
‫אלקטרוליטים‪ BUN ,‬ו קראטינין – בגיל מעל ‪ ,60‬שימוש בדיורטיקה‪ ,‬שלשול‬
‫כרוני‪ ,‬מחלת כליה‪ ,‬מחלת כבד‪ ,‬סכרת‪.‬‬
‫שתן – בסימפטומים אורולוגיים‪ ,‬אם יש קטטר‪ ,‬באפשרות של פרוטזות בניתוח‬
‫‪ - PTT ,INR‬אם יש הסטוריה של דימומים במשפחה או בחולה‪ ,‬שימוש בא"ק‪,‬‬
‫מחלת כבד‪.‬‬
‫ביוכימיה ותפקודי כבד – במחלת כבד‪/‬דרכי מרה‪.‬‬
‫בדיקת הריון – כל אישה בגיל הפוריות (אלא אם אחרי כריתת רחם)‬
‫גזים בדם‪ :‬אם בסכנה לכשל נשימתי‬
‫‪‬‬
‫צילום חזה‪ PA :‬וצדדי – כשיש סיכון מוגבר לסיבוכים ריאתיים‪ ,‬פרוצדורות‬
‫בלב‪/‬חזה ‪ -‬אלא אם צעיר מגיל ‪ 35‬או ידוע על אבנורמליות ב ‪ 6‬חודשים האחרונים‪.‬‬
‫‪‬‬
‫אקג –בגברים מעל ‪ ,40‬נשים מעל ‪ 50‬או אם יש בעיה קרדיו‪-‬וסקולרית‪ ,‬אריתמיה‬
‫או סכרת‪.‬‬
‫רכיבי דם‪:‬‬
‫סוג והצלבה – בסיכון גבוה לדימום‬
‫הזמנת מנות דם‬
‫לגבי בדיקות‬
‫להפעיל שיקול דעת‬
‫לגבי רקע‬