POSTOPERATIVE PERIOD — the period from the moment of the end of operation before recovery of working ability of the patient, during to-rogo hold a complex of the events directed to the prevention and treatment of complications, and also promoting processes of a reparation and adaptation of an organism to the anatomo-physiological ratios created by operation.
Distinguish the next and remote Pct. The next Pct begins with the moment of the end of operation and proceeds from to lay down to an extract of the patient. institutions. The remote postoperative period proceeds out of a hospital and is used for final elimination of the general and local frustration caused by an operational injury (see. Rehabilitation ).
In the next Pct the most responsible is the early period, i.e. the first 2 — 3 days. At this time those changes in activity of bodies and systems which are a direct consequence of an operational injury and anesthesia are most shown. The early Pct depends on features patol, process, apropos to-rogo operation, conditions of the patient before operation, associated diseases, age of the patient, volume and the nature of surgery, complications which can be during operation, from a current of an anesthesia, etc. is made.
After long and traumatic operations, napr, on bodies of a chest and abdominal cavity, on a head and spinal cord, as a rule, patients in early Pct are in intensive care unit and resuscitation (fig. 1 and tsvetn. fig. 4 — 9) or in the postoperative chambers which are specially allocated for territories of surgical department. Control and overseeing by patients are carried out by specially prepared medical staff, in the presence — by means of monitor and monitor and computer systems (fig. 2) registering the main fiziol, parameters of an organism (see. Monitor observation ). If necessary special researches — catheterization of heart and control of pressure in his cavities are carried out, Echocardiography (see), X-ray contrast, endoscopic, radio isotope researches (see. Radio isotope research ), etc.
The main objectives of therapy in early Pct are: maintenance of cordial activity and system blood circulation, function of external respiration, fight against a hypovolemia, hypoxia, disturbances of water and electrolytic balance, metabolism and acid-base equilibrium that especially urgent later traumatic, extensive operations on volume.
On character of a current distinguish the uncomplicated and complicated postoperative period.
Uncomplicated postoperative period it is characterized by moderate disturbances biol, balances in an organism and unsharply expressed reactive processes in an operational wound. In the course of normalization of a metabolism in Pct it is possible to allocate 4 phases: catabolic, transitional, anabolic and phase of increase in the weight (weight) of a body. At once after operation owing to strengthening of intensity of metabolic processes the need of an organism for power and plastic material increases, edges in the conditions of limited intake of nutrients it is provided generally at the expense of internal reserves of an organism by stimulation of catabolic processes with the corresponding hormones (catecholamines, glucocorticoids). As a result release of nitrogenous slags with urine increases, there is a negative nitrogenous balance, the disproteinemia, increase in concentration free fat to - t in blood, etc. is observed. Disturbance of carbohydrate metabolism is shown by a postoperative hyperglycemia due to the increased formation of glucose from a glycogen and strengthening of a gluconeogenesis. Called this condition of V. A. Oppel «small surgical diabetes». Resulted from hyperfunction of adrenal glands and the strengthened disintegration of proteins hyperpotassemia (see) causes development of postoperative acidosis (see). Already in the nearest future after operation the shift of acid-base equilibrium (see) aside metabolic is observed alkalosis (see) at the expense of a hypovolemia, a hypochloraemia and hypopotassemias (see). This phase is characterized by a lose of weight of the patient. In a transitional phase there comes balance between processes of disintegration and synthesis, hyperfunction of adrenal glands decreases. Receipt in an organism of the increased amounts of nutrients creates conditions for approach of the anabolic phase which is characterized by dominance of processes of synthesis under the influence of hypersecretion of anabolic hormones (insulin, androgens, somatotropic hormone). This phase proceeds to a complete recovery an organism of a pool of structural proteins and uglevodnozhirovy reserves then there comes the phase of increase in weight of the patient.
In the first days of the patient pains in a wound, the general weakness, lack of appetite, thirst disturb. Temperature — within 37 — 38 °, in blood a moderate leukocytosis (9000 — 12 000) with a deviation to the left. The meteorism, the complicated urination connected with forced situation in a bed or a reflex origin is sometimes noted.
Regime of the patient depends on the nature of surgery. As a rule, within 2 — 4 days the bed rest is shown. When activation of patients for one reason or another moves away, a measure of the prevention of postoperative complications is to lay down. physical culture.
Feeding habits in Pct in many respects depend on the specific nature of operation, a condition of the patient etc. Feeding after the operations which are not followed by opening of a gleam went. - kish. a path, begin usually for the 2nd days with small portions of liquid food. With 5 — the 6th days of patients gradually transfer to the general diet. As a rule, the operational wound is examined next day after operation. During the healing by its first intention seams on a neck can be removed on the 5th, in other areas — on 6 — the 8th days. At weakened and onkol, seams remove patients later, on 11 — the 16th days.
At an uncomplicated current of Pct the general leaving (see) for the patient comes down to his turning several times a day, to a raspravleniye of folds on linen, to wiping of a body camphoric alcohol twice a day, to implementation of passive movements in all joints, to rinsing of an oral cavity solution of hydrosodium carbonate or Furacilin. According to indications carry out the general massage. For the prevention of parotitis recommend chewing gum, suction of a lemon, for prevention of pulmonary complications — activation of the patient, LFK, massage, mustard plasters.
At a smooth current of Pct appoint the cardiacs, respiratory analeptics anesthetizing. For anesthesia in Pct well proved the DPA method — long peridural anesthesia (see Anesthesia local) which consists in introduction to peridural space of mestnoanesteziruyushchy drugs (Trimecainum, Dicainum). DPA interrupts flows patol, impulses from the operated bodies, removes painful sensitivity, without oppressing a tussive reflex, and promotes recovery of a vermicular movement went. - kish. path. After operation apply to removal of a pain syndrome also inhalation of oxygen with nitrous oxide by means of the device of a discontinuous flow (see. Inhalation anesthesia).
For the purpose of correction of acid-base equilibrium and performing disintoxication therapy, especially after big traumatic surgical interventions, under constant laboratory control carry out intravenous injections of solutions of glucose, electrolytes, krovezamenyayushchy liquids to Pct etc. (see. Infusional therapy).
In Pct the physiotherapy exercises are widely used, edges contribute to normalization of the broken functions of an organism, first of all due to all-tonic action of physical exercises. Breathing exercises improve ventilation of the lungs and reduce developments of stagnation in them, reduce nausea. The movements stimulate a peristaltics of intestines in hip joints, promote a passage of flatus. Peripheric circulation improves due to the movements in small joints. Use of physical exercises is prevention of a vein thrombosis, and also promotes acceleration of processes of healing of a postoperative wound, prevents formation of commissures, prepares the patient to full household and work. The technique of LFK is under construction taking into account features of an operative measure, age and a condition of the patient. In the absence of contraindications (them only the surgeon defines) to lay down. the gymnastics is appointed after thoracic operations in several hours and next day after abdominal operations. The technique of LFK includes 3 periods: early (to a removal of sutures), late (to an extract from a hospital) and remote (before recovery of working capacity).
In the first period in the first three days of exercise are carried out at slow speed for all joints of extremities. After abdominal operations load of muscles of a prelum abdominale is limited. Light massage of a thorax from a back promotes elimination of developments of stagnation, activation kro-vo-and lymphokineses, to improvement of breath. The movements by legs should be carried out with an incomplete amplitude, without tearing off feet from a bed (exercises in small joints repeat 5 — 8 times, in average and large 4 — 6 taking into account reaction of an organism). After operations on bodies of a thorax limit the movements in a shoulder joint on the party of operation. Initial positions — lying on spin and on one side. Gradually general loading is raised due to performance of new exercises. Duration of occupation in the first period of 10 — 15 min. In the second period carry out exercises for all muscular groups, gradually increase amplitude of movements and bring to full. After abdominal organs operations first of all pay attention to strengthening of muscles of a stomach, after operations on bodies of a thorax — to strengthening of muscles of a trunk and recovery of mobility in a shoulder joint on the operated party. Classes can be given in an office of LFK, using exercises with objects (gymnastic sticks, dumbbells, etc.), on shells (wall bars, a bench, etc.), and also different types of walking. Each exercise repeats 10 — 12 times, duration of occupation of 20 — 25 min. In the third period enter the all-developing exercises for all muscular groups. Intensity of loading increases even more, duration of occupation of 30 — 40 min. Along with occupation to lay down. gymnastics appoint the dosed walking (from 500 m to 2 — 3 km), and also walking on skis, swimming, rowing, etc.
In Pct the physical therapy is of great importance. In the first three days after operation for decrease in pain and prevention of edematization and a hematoma appoint a local hypothermia to 20 — 30 min. with a break on 1 — 2 hour, 5 — procedures. For activation of mineral metabolism, increase in immunobiological processes at a normal current of Pct in 7 — 10 days the general UF-radiation is shown (see. Ultraviolet radiation) according to the accelerated scheme in combination with an electrophoresis of calcium on a collar zone. At development of atonic paresis of intestines carry out electrostimulation of muscles of intestines (see Electrostimulation) or influence area of a celiac texture impulse currents (see), ultrasound, microwaves. The delay of an urination is the indication for purpose of a high-frequency therapy (an inductothermy, UVCh-therapies, microwaves, UF-radiations and applications of paraffin on area of a bladder.
The current of uncomplicated Pct is characterized by gradual and everyday improvement of a condition of the patient. In cases when this process is dragged out, it is necessary to suspect emergence of these or those complications first of all.
The complicated postoperative period. Complications can be observed after any operation, but more often they develop after big traumatic operative measures as on bodies of a chest cavity (a pneumonectomy, an extirpation of a gullet, etc.), and abdominal (a gastrectomy, a pankreatoduodenalny resection, a resection of a stomach, liver, reconstructive operations on went. - kish. path and biliary tract, etc.).
During the first hours or days after operation can arise bleeding (see), connected with an insufficient hemostasis during operation or owing to sliding of a ligature from a blood vessel. Internal bleedings are especially dangerous. In later terms perhaps arrosive bleeding connected with fusion of a vascular wall purulent process.
Blood loss, and also inadequate anesthesia promote development of postoperative shock (see). The leading links in a pathogeny of this complication are disturbances of microcirculation in fabrics and metabolism of cells. At emergence of signs of shock (blanching of skin, its grayish shade, cyanosis of nails and lips, small frequent pulse, low the ABP) to the patient needs to create absolute rest, to warm hot-water bottles; intravenous and Intra arterial hemotransfusion and blood-substituting liquids, administration of hormones, vitamins, cordial and analgetic means, an oxygenotherapy is shown.
From complications from respiratory system atelectases of a lung meet (see. Atelectasis ) and pneumonia (see. Pneumonia ). More often they arise after lung operations, is more rare at operative measures on abdominal organs; are found, as a rule, on 3 — the 4th day after operation. According to N. S. Molchanov (1971), in Pct atelectatic, aspiration, hypostatic, infectious and intercurrent pneumonia is observed. Weight of a current and the forecast of pneumonia depend on prevalence of defeat (one-or bilateral), the nature of pneumonia (focal, drain or abscessing); it can also develop in the only available lung. In a wedge, a picture of postoperative pneumonia and atelectases symptoms prevail respiratory insufficiency (see), expressed in different degree. In diagnosis the research is rentgenol, decisive. Treatment complex — antibiotics, streptocides, an oxygenotherapy etc. Use of sanatsionny is effective bronkhoskopiya (see).
Prevention of pulmonary complications — respiratory gymnastics, early activation of the patient, banks, mustard plasters. Complications from a throat and a trachea most often develop after an intubation anesthesia. In these cases apply UVCh-therapy (see), microwave therapy (see), and also UF-radiation of a throat, trachea and a collar zone.
Acute heart failure (see), complicating a current of Pct, begins more often as left ventricular, and further quickly enough turns into insufficiency of both ventricles. Intravenous administration of large amounts of liquid, especially against the background of available for a sick atherosclerotic cardiosclerosis, aortal defect, an idiopathic hypertensia, etc. happens a provocative factor usually. Clinically heart failure is shown by feeling of an acute shortage of air, perspiration, pallor, cyanosis of lips, tachycardia, allocation of a bloody phlegm, swelling of cervical veins, painful increase in a liver etc. At emergence of this complication appoint cardiac glycosides, diuretics. Prevention — presurgical training of patients taking into account the available cardial pathology, individual scoping of intravenous injections.
At development of disturbances from outside went. - kish. a path in the first days after operation are observed nausea (see) and vomiting (see). Single vomiting does not demand special to lay down. actions; it is important to remove emetic masses from an oral cavity for the purpose of prevention of aspiration them in respiratory tracts at the patients who did not completely leave an anesthesia in time. At the repeating vomiting use antiemetic drugs of a fenotiazinovy row (aminazine, Pipolphenum, etc.), carry out sounding of a stomach and evacuation of its contents (see. Sounding of a stomach ). In some cases it is reasonable gastric lavage (see) that demands extra care from the patients who underwent stomach and duodenum operation. At persistent vomiting enter a stylet for continuous aspiration of contents into a stomach. It is important to keep quantitative and qualitative account of the evacuated contents since during the sounding the liquid rich with mineral salts is removed. To prevent reduction of volume of the circulating blood and disturbance of water and electrolytic balance, to the patient enter salt solutions.
Occasionally arises hiccups (see), edges several hours and even can proceed days. In such cases the injection of atropine in combination with aminazine, Pipolphenum or Suprastinum is recommended. The drug-resistant hiccups can stop after vagosympathetic blockade by solution of novocaine (see. Novocainic blockade ).
Paresis of intestines is quite often observed. The most essential in an etiology and a pathogeny of a paretic state it is considered to be disturbance of the activity of century of N of page innervating intestines, disturbance of atsetilkholinovy exchange with oppression of cholinergic systems, irritation mekhano-and chemoceptors of a wall of a gut at its re-stretching, deficit of hormones of adrenal glands, frustration water and electrolytic (hypopotassemia) and protein metabolism etc. Treatment and prevention of paresis of intestines are performed taking into account all these pathogenetic mechanisms (see below).
A dangerous complication is hepatonephric insufficiency (see. Gepato-renaljny syndrome ), in development the cut plays an essential role a reference state of a liver. Most often it arises at the patients operated concerning the mechanical jaundice caused by cholelithiasis, cancer of a pankreoduodenalny zone, cirrhosis is more rare — other diseases. The earliest symptoms of hepatonephric insufficiency — jaundice, tachycardia, hypotension and an oliguria. The meteorism, a partial delay of a chair and gases, nausea, vomiting, vomiting, accumulation in a stomach of a large amount of liquid of brown color, apathy, drowsiness, block, confusion of consciousness, nonsense, motive excitement, euphoria etc. are observed. Hemorrhagic diathesis in the form of hypodermic hemorrhages, nasal bleedings, bleeding of gums etc. is possible. In blood the level of bilirubin, ammonia, residual nitrogen at rather low content of urea increases. Treatment of hepatonephric insufficiency complex: injections of solutions of glucose, glutamrgaovy to - you, drugs of calcium, hydrosodium carbonate, cocarboxylase, rat anti-acrodynia factors, B15, corticosteroids. At serious condition of the patient hyperbaric oxygenation, a hemodialysis, hemosorption, an intra time-talnoye administration of medicines and oxygenic blood, including by means of the arterioportal-ny shunt are shown. The method of an artificial diuresis by means of lasixum and Mannitolum at adequate administration of liquids and salts is applied to the prevention of hepatonephric insufficiency.
A terrible complication of Pct are fibrinferments (see. Thrombosis ). Most often in clinic vein thromboses of extremities meet (see Thrombophlebitis), the main symptoms to-rykh are pains on the course of veins, puffiness of an extremity and strengthening of the venous drawing. A special form of trombotichesky complications in Pct — a thromboembolism of a pulmonary trunk and pulmonary arteries (see. Pulmonary trunk, Embolism of a pulmonary artery). The leading reason of a thrombogenesis — the disturbance of coagulant system of blood (see) which is shown in hypercoagulation. It is promoted by an operational injury, at a cut the hemostasis as a result of disturbance of a vascular wall, blood loss, a hypoxia, shifts of water and electrolytic balance, reaction simpatiko-adrena-lovoy systems, releases of thromboplastin changes. The thrombogenesis is promoted by also long bed rest in Pct. According to most of scientists, hypercoagulation remains to 5 — the 6th days after operation and this period is considered the most tromboopasny. There is also a point of view that irrespective of a type of an operative measure in the first 3 — 5 days activation of anticoagulative factors and oppression of coagulant factors is noted nek-paradise, and then the return phenomenon is observed. Assessment of coagulant system of blood in respect of a thrombogenesis is difficult since by data koagulogramma (see) it is possible to judge its state only at the time of registration. Indicators of a koagulogramma can change during anesthesia, operation, etc. However studying of a series koagulogramm to, in time and after operation taking into account the postponed thrombophlebitis, inflammatory processes in a small basin, existence of a varicosity of the lower extremities, disturbance of a lipometabolism, the accompanying cardiovascular diseases, age (more than 50 years) promotes identification of tromboopasny patients for carrying out corresponding to lay down. actions. Exists specific and nonspecific the profilak-geek of thromboses. Specific prevention includes anticoagulating therapy (see. Anticoagulants ) — use of anticoagulants of direct action (heparin) and indirect action (neodicoumarin, phenyl in, Syncumarum, etc.). Nonspecific prevention consists in daily massage, carrying out respiratory gymnastics, elastic bandaging of the lower extremities, early activation of the patient. The question of prevention of thromboses is very difficult and finally is not solved. Most of researchers considers that anticoagulating prevention should be begun with 1 — the 2nd day after operation; there is an opinion that with 3 — the 4th day.
Occasionally in early Pct develops hyper thermal syndrome (see), connected with toxic wet brain. Diagnosis usually does not cause difficulties. Treatment — a kraniotserebralny hypothermia (see. Hypothermia artificial ), spinal punctures, administration of pyramidon. aminazine, Pipolphenum.
At formation of a hematoma or inflammatory infiltrate in Pct appoint UVCh-therapy, edges promotes a rassasyvaniye of the remains of blood and reduces probability of distribution of a purulent inflammation. If infiltrate it is long does not resolve. along with thermal influences carry out an electrophoresis of iodine, dionine, a lidaza. Ultrasonic therapy gives good resorptional effect (see). Sometimes suppuration of an operational wound takes place. In these cases it is necessary to remove seams. to part edges of a wound and it is good to drain it. Clarification of an operational wound is promoted also by radiation by its short UV rays (3 — 5 times). Further treatment is carried out by the principle of treatment of purulent wounds (see. Wounds, wounds ).
The most terrible of inf. complications in Pct is sepsis (see). More often it develops at urgently operated patients with acute diseases of abdominal organs against the background of peritonitis or at insolvency of seams of an anastomosis. Its development after the operations executed concerning pyoinflammatory diseases (osteomyelitis, abscess, phlegmon) is possible. Treatment consists in elimination of the infectious center, performing antiinflammatory therapy, etc.
In the complicated Pct the disturbance of process of normalization of a metabolism which is shown in lengthening of a catabolic phase that can lead to exhaustion of an organism and delay of processes of healing is noted; loss by an organism more than 40% of weight is life-threatening. From preventive and to lay down. the purpose showed vitamin therapy, providing an organism with enough proteins, fats and carbohydrates, and in nek-ry cases — use of anabolic hormones.
Postoperative psychoses — a kind of acute symptomatic psychoses — develop usually in the next Pct. The classical description of symptomatology of postoperative psychoses belongs to S. S. Korsakov, Kleyst (To. Kleist). Acute mental disorders arise at 0,2 — 1,6% of the patients who underwent band operations. They develop on 2 — the 9th days after operation, last of several hours to 2 weeks. The stereotype of development of postoperative psychoses can be presented as follows: operation — a somatogenic adynamy — exogenous type of reaction (see Bongeffer exogenous types of reaction, t. 10, additional materials); emergence of so-called transitional syndromes is sometimes possible (see. Symptomatic psychoses). Against the background of the expressed physical and mental adynamy with dominance of the phenomena of irritable weakness such syndromes of the broken consciousness as a delirium most often develop (see. A delirious syndrome), often gipnagogichesky oneiroid (see. Oneiric syndrome ), an amentia (see. Amental syndrome ), devocalization (see), more rare twilight stupefaction (see); anamnestic frustration, and also a convulsive syndrome are possible. Rather infrequently exogenous type of reactions is replaced by such transitional syndromes as hallucinatory paranoid (see. Paranoid syndrome ), depressive (see. Depressive syndromes), maniacal (see. Maniacal syndromes ), disturbances in the form of the phenomena of a derealization, frustration already seen and never seen, and also frustration of a body scheme. Frequency of emergence and feature a wedge, pictures of acute mental disorders depend on character of a somatopathy and on on what body operation is made. After heart operations disturbance of mentality meets twice more often than at other band surgical interventions, and develops, as a rule, in the form of an alarming depression; the kardiofo-bichesky phenomena, vital fear, derealizatsionny frustration, auditory hallucinations are typical; syndromes of the broken consciousness — Delirious, Oneiric, amental are less often observed. Mental disorders are followed passing nevrol, symptomatology. After operations on went. - kish. a path there is an acute paranoid more often, syndromes of the broken consciousness are more rare. After operation of transplantation of a kidney in early Pct the Delirious syndrome with dominance of a gnpnagogichesky delirium can develop. Because of not expressiveness of psychomotor excitement psychosis can remain not distinguished. The exception is made by delirious episodes with euphoria and considerable psychomotor excitement against the background of a polyuria (in the first days of functioning of a transplant). Short-term derealizatsionny frustration are also possible. Against the background of the massive hormonal therapy used at transplantation for the purpose of an immunosuppression sometimes develop: katatono-oneiric and affective frustration. Against the background of crises of rejection the state close to alarming sad with vital fear, epileptiform attacks is observed. Gynecologic operations, in particular removal of a uterus, sometimes are followed by a psychogenic depression with suicide thoughts. Clinically similar depressive psychoses of the psychogenic nature with melancholy, thoughts of big disease severity or the depressive and paranoid phenomena with the ideas of the relation can arise after operations for a malignant new growth of a throat, after the amputations of a mammary gland, extremities and other operations connected with serious cosmetic defects. Postoperative psychoses should be differentiated from aggravations or manifestation of endogenous psychoses, a tremens (see. Alcoholic psychoses, Maniac-depressive psychosis, Schizophrenia). Both somatogenic, and psychogenic factors participate in an etiology of mental disorders after operations. In a pathogeny of mental disorders the leading place is taken by factors of toxicosis, hypoxia, an allergic sensitization, shifts of ionic balance, endocrine changes, patol. Interoception from the injured bodies and fabrics. The important role belongs to character patol, process in general, to a condition of compensatory opportunities of a brain, and also premorbidal features of the personality. Due to a possibility of destructive tendencies, the suicide actions caused by psychosis strict supervision of patients is necessary that demands preparation of an average and junior medical staff. For treatment of postoperative psychoses according to indications neuroleptics and tranquilizers in combination with an intensive care of the main pathology can be used. Postoperative psychoses usually come to an end with absolute mental recovery. Predictively change of a delirium or oneiroid by an amental syndrome or its primary development is adverse.
Features of the postoperative period depending on the nature of surgery
abdominal organs Operations. The pct after abdominal organs operations has three idiosyncrasies: frequent development of bronchopulmonary complications, need of parenteral food, and also paresis went. - kish. a path, developing usually to some extent practically at all patients. Bronchopulmonary complications are caused by hypoventilation of lungs due to restriction of diaphragmal respiration against the background of postoperative pains, a meteorism, localization of operation in an upper half of a stomach. Prevention of bronchopulmonary complications and their treatment — see above.
Purpose parenteral food (see) providing an organism with enough proteins, fats, electrolytes and calories is. The amount of the liquid entered usually intravenously depends on weight of a condition of the patient, character and volume of surgical intervention and indicators of a homeostasis. When the patient begins to drink and eat through a mouth, the volume of transfusions reduce, and then absolutely cancel them.
Symptoms of paresis went. - kish. a path the feeling of swelling and weight in a stomach, vomiting or vomiting congestive gastric contents, abdominal distention, a delay of a chair, not passage of flatus, sharp weakening of intestinal noise are at auscultation etc. As a rule, they arise at the end of the 2nd — the beginning of 3 days after operation. For the purpose of prevention and treatment of this state next day after operation carry out constant or periodic (2 — 3 times a day) sounding of a stomach (see), and from the 2nd day put enemas (see) — usual, hypertensive, vaseline, and also across Ognev (30 ml of glycerin, 30 ml of hydrogen peroxide and 40 ml of 10% of solution of sodium chloride). Enemas work after preliminary medicinal stimulation much more effectively motor evakuatornoy functions went. - kish. path. For this purpose appoint ganglioblokator (Dimecolinum), prozerin, Pituitrinum, ubretid. Administration of electrolytes, especially potassium which stimulates work of intestines is of great importance. In some cases the good effect is given outside electrostimulation of intestines (see. Electrostimulation ), the prolonged peridural anesthesia (see. Anesthesia local ).
When disturbances motor evakuatornoy functions went. - kish. a path diagnose still to or during operation, resort to a temporary gastrostomy on a foul-evsky catheter (see. Stomach, operations ) or to various options of an intubation of intestines (see). Motor evakuatornoy functions of intestines contribute to normalization also early reception of liquid and food through a mouth, an early rising and LFK, failure from prolonged use of the drugs which are slowing down a passage of food masses on went. - kish. to a path.
After stomach operations, a duodenal and small bowel the first 2 days of the patient is on parenteral food. For the 3rd days about 500 ml of liquid are allowed to drink (waters, tea, fruit juice, broth and kissel). In the absence of stagnation in a stomach since 4 days appoint the diet No. 1A excluding the substances which are strong activators of secretion and also the mechanical, chemical and thermal substances irritating a mucous membrane of a stomach (food is given only in a liquid and kashitseobrazny look). With 7 — the 8th days — a diet of «N» 1 or No. 5 (mechanically and chemically sparing diet): food is given in a liquid and kashitseobrazny look, more dense food — in boiled and prershushchestvenno the wiped look (see clinical nutrition). In the first two-three days after operation 2 times a day make aspiration of gastric contents via the probe, in the next days continue sounding of a stomach according to indications. Allow to sit and go with 2 — 3 days. Seams remove on 7 — the 8th days, and at the weakened patients — on 12 — the 14th days. The extract of patients from surgical department is made on 8 — the 15th days.
After a gall bladder operations — cholecystectomias (see), cholecystostomies (see) — since 2 days appoint a diet No. 5A. After creation of a biliodigestivny anastomosis a power supply system same, as after stomach and duodenum operations. At a smooth current of Pct drainages from an abdominal cavity delete for the 3rd days, tampons — on 4 —-e days, a drainage from the general bilious channel at passability of its distal department — on 15 — the 20th days. Allow to sit and rise after the termination of drainage of an abdominal cavity. Depending on the nature of surgery of patients write out on 10 — the 25th days.
After a large intestine operations (see. Intestines ), followed by creation of a colic anastomosis, since 2 days appoint a zero table (the most sparing diet with inclusion of digestible products), reception of liquid, as a rule, is not limited. From 5th days transfer to a diet No. 1. Since 2 days within 5 days of the patient drinks a liquid paraffin on 30 ml 3 times a day. The enema is not appointed, as a rule. Maintaining patients with to-lostomami is carried out as well as after a resection of a large intestine. If colostomy (see) it is made in the emergency order, the gut is opened as it is possible later when unions between the removed gut and a parietal peritoneum manage to be formed. At the expressed phenomena impassability of intestines (see) it is necessary to punktirovat the removed gut a thick needle or to open its gleam with an electroknife throughout 1 — 1,5 cm. In the absence of the phenomena of the increasing intestinal impassability the gut is opened on 2 — the 4th days after operation. Write out patients after a large intestine operations on 12 — the 20th days.
The heaviest complication after abdominal organs operations is insolvency of the stitches put on a wall of a stomach or intestines, and an anastomosis between various departments went. - kish. path. Insolvency pishchevodnokishechny and esophageal and gastric is more often observed, is more rare than a gastrointestinal and colic anastomosis, after a resection of a stomach — insolvency of seams of a stump of a duodenum.
Klien, a picture of insolvency of seams is various. Sometimes it is shown on 5 — the 7th days by the sudden beginning which is followed by sharp abdominal pains, a muscle tension of a front abdominal wall, symptoms of irritation of a peritoneum, a stake-laptoidnym a state. More often since 3 — 4 days dull aches in a stomach, usually without accurate localization develop, temperature rises to 38 — 39 °, persistent paresis went. - kish. the path does not give in to conservative actions, symptoms of irritation of a peritoneum gradually accrue. For diagnosis of insufficiency of seams carry out rentgenol, a research with contrasting went. - kish. path. In doubtful cases the «rummaging» catheter which is entered into an abdominal cavity after removal from an operational wound of one-two seams, and also a laparoscopy (see is used. Peritoneoskopiya ). Treatment at insolvency of seams — operational. Imposing of additional seams on area of defect in a wall of hollow body or an anastomosis, even with peritonization of the line of seams a lock of a big epiploon, not always effectively. Often repeatedly put stitches are cut through. In this regard at insolvency of seams on a small and large intestine removal of the respective site of a gut on an abdominal wall is reasonable; in other cases it is necessary to be limited to drainage of an abdominal cavity (see. Drainage ) and parenteral food.
Insufficiency of seams is the most frequent reason of postoperative peritonitis (see). Due to the broad use of antibiotics a wedge, a picture of postoperative peritonitis changed. According to I. A. Petukhov (1980), postoperative peritonitises can be sluggish, atypical, with greased a wedge, a picture, and acute, reminding perforation of hollow bodies.
Early symptoms of peritonitis are the frequent small soft pulse which is not corresponding to temperature and the general condition of the patient, the accruing paresis of intestines, morbidity of a stomach, a muscle tension of an abdominal wall, excitement, concern, euphoria or, on the contrary, a depression, sleeplessness, the increasing dryness in a mouth, thirst, a hiccups, nausea and vomiting. Treatment — early relaparotomy, elimination of the center of an infection, sanitation of an abdominal cavity and a decompression of intestines.
In Pct after intra belly operations, especially on a stomach, a pancreas and biliary tract, acute pancreatitis can develop (see). It are the main reasons direct Traumatization of a pancreas during intervention and disturbance of outflow from bile-excreting and pancreatic channels. Usually postoperative pancreatitis is shown on 3 — the 4th days after an operative measure. Diagnosis of pancreatitis in Pct is difficult since often it develops against the background of a heavy postoperative current and has the erased wedge, a picture. In these cases dynamic overseeing by the level of amylase in blood and urine is important. Treatment of pancreatitis in Pct usually conservative: cytostatic and anti-fermental drugs, novocainic blockade, carrying out an artificial diuresis, local hypothermia, antibiotics, etc. At emergence of symptoms of peritonitis or formation of an abscess operation is shown, aim a cut — removal of the sequestered sites of gland, local administration of inhibitors of enzymes, drainage of an omental bursa and an abdominal cavity.
Serious complication of Pct is mechanical Impassability of intestines (see), the reason the cut most often happens commissural process owing to traumatization of a serous cover went. - kish. a path during operation and restriction of mobility of intestines in places of damage. Early diagnosis presents considerable difficulties since initial symptoms of mechanical impassability of intestines and postoperative paresis went. - kish. a path are very similar. However the persistent delay of gases, abdominal distention, rumbling in intestines, colicy pains, etc. shall guard the doctor. Increase a wedge, and rentgenol, signs of impassability of intestines is the indication to relaparotomy Operation comes down to elimination of impassability and to a decompression of a stomach and intestines.
Gastrointestinal bleeding (see), arising sometimes after stomach operations, usually appears on 1 — the 2nd days after operation and is followed by typical symptomatology. Treatment of such patients, as a rule, conservative: a gastric lavage ice water or aminocaproic to - that, reception orally thrombin, an injection of Vikasolum, calcium chloride etc. Effective can be a diathermic or laser coagulation of a bleeding point (see Diathermocoagulation, the Laser) at gastroscopy. Resort to relaparotomy according to indications when all methods of conservative treatment are exhausted.
Quite often, especially after stomach operations, the anastomositis develops (see. Postgastrorezektsionny complications ). It arises usually on 3 — the 4th days after operation and is shown by persistent stagnation in a stomach or its stump, sometimes constant dull aches in an upper half of a stomach, subfebrile temperature. The diagnosis of an anastomositis is made on the basis of data of a X-ray and endoscopic inspection (see Endoscopy). At treatment of an anastomositis limit reception even of liquid or completely transfer to parenteral food and carry out antiinflammatory treatment. It is effective roentgenotherapy (see) — it is fractional on 25 — 30 I am glad (0,25 — 0,3 Gr) on a session, only 5 — 6 sessions, the general dose 150 — 200 I am glad (1,5 — 2 Gr). Also endoscopic intubation of an anastomosis a thin catheter is reasonable that allows to enter enterally liquid nutritious mixtures and thus to limit or exclude parenteral food. Current of an anastomositis, as a rule, very persistent. Even in case of intensive treatment passability of an anastomosis is recovered only in several days, and sometimes and weeks.
At the oncological, sharply weakened and exhausted patients, at patients with a diabetes mellitus and with suppuration of an operational wound can arise eventration (see) that is the indication to repeated surgery — sewing up of a front abdominal wall.
Operations on bodies of a chest cavity. Surgical interventions on bodies of a chest cavity, especially on heart, are among the heaviest, traumatic; quite often make using a hypothermia, artificial circulation and massive transfusions. At such category of patients before operation the respiratory insufficiency, disturbance of blood circulation, an anoxemia, a hypoxia connected with the basic patol is, as a rule, observed. process; in Pct these disturbances usually amplify more often than at operations on other bodies that causes specifics of Pct.
The complex of preventive also to lay down. actions after thoracic operations it is wide. Taking into account indicators of the volume of the circulating blood (VCB) apply intravenous infusions of crystalloid and colloid plasma substitutes, components and blood preparations to correction of a hypovolemia, whole blood. Apply oxygen therapy to maintenance of adequate external respiration (see), according to indications — the artificial ventilation of the lungs continued after operation (see. Artificial respiration), if necessary — hyperbaric oxygenation (see); for fight with haemo - and pheumothorax carry out active aspiration of contents of a pleural cavity by means of the dosed vacuum (see. Aspiration drainage). At a pneumonectomy evacuation of contents is made strictly according to indications. Free passability of a tracheobronchial tree is provided with aspiration of a secret from respiratory tracts, massage of a thorax, to lay down. physical culture. At patients with the expressed cardiac pathology, hl. obr. after heart operations, decrease in functions of heart, disturbance of endocardiac conductivity and a heart rhythm can be observed. In these cases use the drugs improving pumping function of heart (cardiac glycosides), antiarrhytmic means (lidocaine, Isoptinum, etc.), adrenoblockers (inderal), and also elekt-rokardiostimulyatspyu. After operations with artificial circulation and use of hemodilutions, big on volume, within the first days for regulation of water and electrolytic balance and for the purpose of perhaps early identification of complications from heart and kidneys measure an hourly diuresis. Preventively antibacterial therapy is applied, as a rule, after operations with use of artificial circulation, at patients with the accompanying hron, inflammatory and purulent processes. At prosthetics left (mitral) and right (three-leaved) atrioventricular valves, after operations of aortocoronary shunting with the preventive purpose anticoagulating therapy is shown. Drainage of pleural, pericardiac cavities and a mediastinum is made for control of outside blood loss and removal of excess accumulation of blood and gas depending on the nature of surgery; as a rule, drainages delete on 1 — the 3rd days after operation. At uncomplicated Pct reaction to operation as on a stress is considerably expressed during the first hours and days and gradually decreases to 5 — to the 7th day.
The most frequent and serious complications during the first hours and days after thoracic operations are a circulatory unefficiency (see) and respiratory insufficiency (see). The circulatory unefficiency at operations out of heart is caused by hl. obr. deficit of volume of the circulating blood, at heart operations — more often low cardiac effeciency or a hypovolemia, or their combination. Treatment depends on the reasons which caused complications. The sudden stop of blood circulation in the conditions of intensive observation and treatment arises extremely seldom and is possible at such hardly predicted complications as postoperative myocardial infarction (see), a thromboembolism of a pulmonary trunk and pulmonary arteries (see. Pulmonary trunk, Embolism of a pulmonary artery). After operations using artificial circulation adverse effects of inadequate blood circulation are hypoxemic encephalopathy (see), wet brain (see Hypostasis and swelling of a brain). Treatment conservative: dehydrational therapy, corticosteroids, artificial ventilation of the lungs (AVL), etc.
After heart operations dysfunction of the artificial valve, eruption of the seams fixing the valve prosthesis, endocardiac thrombosis which sometimes is followed by an arterial thromboembolism, a rekanalization of septal defect at its sewing up can be observed. In most cases at these complications a repeated operative measure is required. After lung, bronchial tubes, trachea operations are possible pheumothorax (see), insolvency of seams on a bronchial tube, a trachea, lungs, formation of bronchial, tracheobronchial, thoracic fistulas (see. Bronchial fistula ); after gullet operations — insolvency of seams on a gullet, a pishchevodnozheludochny or esophageal and intestinal anastomosis. At development in later terms of complications of inflammatory character — a mediastinitis, an empyema of a pleura (see. Pleurisy ) — are shown antibacterial therapy (the general and local) and sufficient drainage.
Operations on bodies of urinogenital system. As urological operations often are followed by damage of uric ways and the expiration from a wound of the infected urine, there is a need of drainage of uric bodies and fabrics silicon drainage tubes or rubber and gauze tampons (see. Drainage ), it is frequent on a long term. The best drainage is carried out at vacuum pumping out of wound liquid and urine, a cut promotes removal of contents from «dead space» and, reducing it, prevents development of uric zatek and suppuration of postoperative wounds.
Due to the need to support function of kidneys in Pct and to regulate water and electrolytic balance of an organism much attention is paid by corrections of volume of the circulating blood and acid-base equilibrium. In the first days after operation measure a daily urine, control the content of nitrogenous slags in blood and their allocation with urine.
Food of urological patients in Pct shall be sparing, caloric, well assimilable, vitaminized and not to cause considerable gas generation. At an azotemia limit the use of proteinaceous products.
At persistent vomiting and paresis of intestines hold events, ordinary at these complications, (see above). Considering ability went. - kish. to allocate walls in a gleam of a stomach and intestines various nitrogenous slags, make repeated gastric lavages, it is better solution of hydrosodium carbonate.
After operation on bodies of urinogenital system in 18 — 24 hours patients become more active in a bed and if necessary move on chamber by means of medical staff, and on 2 — the 3rd days start walking independently. The late rising (4 — the 5th days and later) is recommended after nek-ry recovery operations on the uric ways and a crotch, after a nephropexy. In most cases after operation there is a need for performing antibiotic treatment with preliminary definition of sensitivity to them a bacterial flora.
In Pct at urological operations the following complications are observed: a tamponade of a bladder, uric flow (see. Uric became numb ), uric and intestinal fistulas (see. Urinogenital fistulas ), pyelonephritis (see), a septicaemia (see. Sepsis ), hemorrhagic and toksikobakterialny shock, renal failure (see), peritonitis (see), vesicoureteral reflux (see).
Ortopedo-travmatologichesky operations. Many modern operations of ortopedo-herbs-matologicheskiye are heavy intervention for the patient; they are followed by big blood loss and need of an immobilization of bone fragments on long terms. Big blood loss is caused by the fact that the hemostasis in a bone tissue is difficult, and the operational wound represents usually big wound surface. Therefore bleeding after operations can proceed still a long time. In Pct the main objective is compensation of blood loss and normalization of a homeostasis (see. Blood loss ). The immobilization after ortopedo-traumatologic operations is carried out at the expense of internal or outside devices, including pins, plates (see. Osteosynthesis ), distraktsionno-compression devices (see), plaster bandages (see. Plaster equipment), etc. After osteoplastic operations (see. Bone plastics ) rather long immobilization is, as a rule, necessary for adaptation and reorganization of bone transplants. Irrespective of a way of an immobilization of the patient some time shall be in forced situation (on a stomach, on spin, on one side or in other special situation). After endoprosthesis replacement of joints (see. Endoprosthesis replacement ) the immobilization lasts the minimum terms (1 — 2 week) or is absent completely that is connected with need of early movements of the operated extremity.
Owing to a long immobilization of bones and joints contractures and rigidities For the prevention of these complications quite often can develop in Pct, and also for the purpose of recovery of functions of a musculoskeletal system apply to lay down. physical culture. In a technique of its use distinguish two periods — the period of an immobilization of the damaged body and the period after a cast removal. In the first period to lay down. the gymnastics is appointed for joints, free from an immobilization. After a cast removal recovery of function of the struck body begins. In nek-ry cases for this purpose use special devices (see. Mekhanoterapiya ).
Neurosurgical operations. The uncomplicated Pct is characterized by gradual recovery of the broken functions of a brain caused by basic process. Criterion for evaluation of a condition of the patient — the level of his consciousness. If within several hours after operation consciousness is not recovered, it is necessary to think of a complication.
Character of complications after craniocereberal operations is connected with disturbance of regulatory functions of a brain owing to an operational injury and additional, time of irreversible changes in its fabric. It first of all is shown by disturbance of functions of nervous cells and metabolic processes in them, p cut den it blood-brain barrier (see), disturbance of cerebral circulation and processes of a likvorotsirkulyation. Symptoms of disturbance of activity of cardiovascular system and breath, water and electrolytic exchange, functions of pelvic bodies and the motive device are quite often observed.
Considering the general condition of the patient, level of his consciousness, motor and mental performance, nevrol, the status, affective and emotional reactions, allocate two states: one is characterized by excessive decrease in the general activity, another — its increase. Each of these states demands essentially various therapy directed or on activation and stimulation of cortical and subcrustal and trunk structures of a brain, or on decrease in the general level of its functioning by sedatives or a medical and guarding anesthesia. There are transitional options, at to-rykh the main directions of an intensive care are combined.
Vascular therapy is directed to normalization of a vascular tone, permeability of a vascular wall, rheological properties of blood, microcirculation and includes introduction of vasoactive means (sermion, etc.) and low-molecular dextrans (reopoliglyukin). To lay down. the actions directed to normalization of a likvorotsirkulyation depend on the nature of its disturbance. At the intracranial hypertensia which resulted from increase in volume of one of components of contents of a skull (cerebrospinal liquid, blood or an intercellular lymph) use the following methods of treatment: for reduction of volume of cerebrospinal liquid — a lumbar or ventrikulyarny drainage, inhibitors of a karboangidraza, cardiac glycosides; for reduction of volume of blood — respiratory gymnastics, massage, a hyperventilation by means of the artificial ventilation of the lungs (AVL), a giperokspgenation, a hypothermia; for reduction of excess volume of fabric water — glucocorticoid hormones, osmodiuretik, saluretics (see. Hypertensive syndrome). At intracranial hypotension enter the pharmaceuticals stimulating a face-voroproduktsiyu — caffeine, piracetam (nootropil), and improving microcirculation (see. Hypotensive syndrome ). Apply to maintenance of respiratory function an oxygenotherapy) (see. Oxygen therapy ), according to indications — IVL. If IVL proceeds more than 2 — 3 days, is shown tracheostomy (see). It should be made at the patients who are in coma, even at adequate breath and also in case of full paralysis of muscles of a throat and a throat as soon as possible.
The most typical complications: hematoma (see), the ischemic hypoxia of a brain sometimes caused by forced cliping of the main vessels during operation dislocation and a vklineniye, wet brain. Methods of specific, pathogenetic therapy are applied to their elimination. A spinal
cord operations, depending on the level of its defeat, are followed various degree by disturbances of breath and functions of pelvic bodies. At uncomplicated Pct treatment comes down to reduction of pains, at a delay of an urination — catheterization of a bladder. From complications it should be noted development of respiratory insufficiency, trophic disturbances, infectious and inflammatory processes — a pyelocystitis (see. Pyelonephritis ), infected decubituses (see).
After operations on peripheral nerves carry out the therapy providing improvement of a trophicity of nerve fibril, elimination of hypostasis and an inflammation.
Operations on an organ of sight. After band operations on an eyeglobe (antiglauko-matozny operations, extraction of a cataract, extraction of a cataract with implantation of an artificial crystalline lens, a keratoplasty, etc.) patients, as a rule, during 10 — 12 hours after operation are on a bed rest. It is allowed to rise and go from the next day. After operations for amotio retinas (see) — a high bed rest (up to 6 days). Seams from a conjunctiva are removed not earlier than in 7 days after operation. The Supramidny stitches put on a cornea after extraction of a cataract and a keratoplasty are removed not earlier than in 4 — 5 weeks. Medicinal therapy includes purpose of midriatik (1% solution of atropine, 0,25% solution of Scopolaminum, 1% solution of homatropine, 10% solution of a phenylephine hydrochloride, 0,1% solution of adrenaline in drops, applications) for prevention of development of an iritis, an iridocyclitis. After a keratoplasty corticosteroid therapy for suppression of reaction of incompatibility is shown. In the presence of inflammatory exudate in moisture of an anterior chamber of an eyeglobe apply antibiotics of a broad spectrum of activity (under a conjunctiva, intramusculary, intravenously).
The operational injury is followed by emission of prostaglandins promoting development of an iritis and hypostasis of a retina in a macular zone (Ervin's syndrome) in this connection the day before or in day of operation it is reasonable to appoint and continue reception after operation within 5 — 6 days of the drugs blocking synthesis of prostaglandins (indometacin, etc.).
Tactics of maintaining patients after implantation of an artificial crystalline lens depends on the principle of its fixing in an eye. At intrapupil-lyarny fixing of irises-klins-lenses of Fedorov — Zakharova purpose of midriatik can cause a considerable mydriasis and lead to dislocation and dislocation of an intraocular lens in an anterior chamber of an eyeglobe or in a vitreous that can become the reason of development of heavy complications. At the ekstrapupillyarny fixing an iris lenses offered by M. M. Krasnov vnutrikapsulyar-ache implantations of an artificial crystalline lens of B. N. Alekseev maintaining patients same, as after extraction of a cataract. From complications in Pct development is possible iridocyclitis (see). In such cases appoint corticosteroids in drops (Dexasonum, Prednisolonum, a cortisone) or in the form of subconjunctival injections (Dexasonum, a hydrocortisone). At hemorrhage in an anterior chamber of an eyeglobe (see. Hyphema ) subconjunctival injections of fibrinolysin, alpha himo - trypsin, papain and other proteolytic enzymes or administration of these drugs in the form of an electrophoresis are effective.
An origin in Pct. syndrome of a small anterior chamber (see) with increase or decrease in intraocular pressure are: relative pupillary block; a combination of the relative pupillary block with the cyclolenticular block (malignant glaucoma) which develops on the operating table in eyes with the closed corner of an anterior chamber at tendency of the patient to hypertensive crisis; tsilio-choroidal amotio in eyes with considerable filtering of liquid under a conjunctiva after an anti-glaukomatoznykh of operations or outside filtering at ruptures of a conjunctival rag, filtering on a conjunctival seam, and also on a corneal seam at extraction of a cataract and through changes corneas (see). The relative pupillary block is eliminated with purpose of midriatik.
At development of malignant glaucomas (see) extraction of a crystalline lens is shown. Outside filtering is liquidated by imposing of additional seams, a podshivaniye of a silicone seal (tape) or a silicone lens. At a long absence of an anterior chamber of an eyeglobe (within 5 — 6 days) the tsiliarny sclerotomy is shown (see. Sclera ) with recovery of an anterior chamber sterile solutions through a valve puncture of a cornea.
Features of the postoperative period at children. Character of Pct at children is defined anatomo-fiziol. features of the growing organism. These features are most expressed at newborns and at early children's age though in various degree they remain during the entire period of formation of an organism. In Pct an important role is played by removal of pain since at children, especially at early children's age, response to an injury always has giperergichesky character and therefore the painful factor can cause diffusion disturbance of all vital functions, first of all gas exchange and blood circulation. For the warning of pains to children enter intramusculary analginum, Promedolum, sometimes in combination with fentanyl, Dimedrol, aminazine. Doses depend on age of the child. Peridural anesthesia is effective (see Anesthesia local). In nek-ry cases the pain syndrome is well stopped by acupuncture (see. Acupuncture , Reflexotherapy ).
In Pct at children disturbances of a homeostasis since they immaturity of compensatory mechanisms, lack of necessary thermogenesis exclude a possibility of adequate self-control and correction of disturbances of the main vital signs are most dangerous. First of all it is necessary to eliminate disturbances of blood circulation which are connected with a hypovolemia. It is caused by rather bigger need of the child in volume of blood on a weight unit (masses) of a body and danger even of «small» blood loss. So, reduction of volume of the circulating blood by 12 — 14% at the newborn child is equivalent on the negative influence on an organism to loss of 20% of volume of blood at the adult. The hypovolemia korrigirutsya by packed red cells transfusion, odnogruppny blood, plasma, albumine, Polyglucinum. Apply glyukozonovoka-inovy mix, Droperidolum to a spasmolysis of arterioles. After that administration of strophanthin, cocarboxylase, 20% of solution of pantothenate of calcium, ATP in age dosages is reasonable.
One of features of Pct at newborn children and children of early age is danger of disturbance of temperature balance that it is connected with imperfection of thermal control at them. Opening of a thorax or abdominal cavity, eventration of intestines, intravenous injections during operation can lead to a hypothermia. For prevention of a hypothermia of newborns operate on special tables with heating or having imposed them with hot-water bottles. Temperature in the operating room shall be not less than 24 — 26 °. The liquids poured intravenously need to be warmed up to room temperature. From the operating room of children transport the covered and laid over hot-water bottles or in special couveuses.
Also the hyperthermia is not less dangerous. Fervescence St. 39,5 ° can lead to spasms, wet brain and even by a lethal outcome. In Pct the hyperthermia is more often connected with infectious and inflammatory complications.
For elimination of a hyper thermal syndrome of the child cool by means of the fan, reveal him, rub off alcohol or ether, wash out a stomach and a rectum a cold water, intravenously enter the cooled solutions etc. In the absence of effect injections of pyramidon, analginum, aminazine in age dosages are shown.
For maintenance of normal acid-base equilibrium carry out correction of disturbances of a hemodynamics, gas exchange, temperature balance and effective anesthesia. When these conditions are satisfied, but the metabolic acidosis nevertheless comes, intravenously enter 4% solution of hydrosodium carbonate, quantity to-rogo is calculated on a formula: deficit of the bases (BE) X 0,5 X weight (weight) of a body. The metabolic alkalosis is eliminated with intravenous administration of potassium chloride.
Most often in Pct disturbance of breath and gas exchange takes place (see. Respiratory insufficiency ). At children oxygen requirement is weight unit bodies more, than at the adult. At the same time as a result of comparative narrowness of upper respiratory tracts, a horizontal arrangement of edges, high standing of a diaphragm, rather small size of a thorax and weakness of respiratory muscles the respiratory system of the child experiences considerable strain. It is natural that disturbances of passability of respiratory tracts, the inflammation and hypostasis of mucous membranes, painful hypoventilation, restrictive disturbances of breath, an injury of a chest wall and pulmonary fabric at the child quicker, than at the adult, lead to disturbance gas exchange (see). Free passability of respiratory tracts is provided with the correct position of the child in a bed (the raised head end of a bed, the child shall lie on healthy, not operated, the party), aspiration of contents from the stomatopharynx and a tracheobronchial tree prolonged by a nasal intubation.
The anoxemia is korrigirut inhalations of the warm and moistened oxygen in concentration of 40 — 60% by means of a mask, nasal catheters, in an oxygen tent. For prevention and treatment of respiratory frustration in Pct at children spontaneous breath with the increased resistance on an exhalation is very effective. This method is shown with a low partial pressure of oxygen, a fluid lungs, aspiration pneumonia, a «shock» lung, and also for prevention of microatelectases. The increased resistance in respiratory tracts is useful at the hypoventilation connected with a post-narcotic depression and upon transition from IVL to spontaneous breath. IVL (see. Artificial respiration ) it is shown when spontaneous breath is absent or it is broken so that is not able to provide gas exchange. Criteria for evaluation of degree of respiratory insufficiency and transfer into IVL are the level of partial pressure of oxygen of 50 — 45 mm of mercury. below, level of partial pressure of carbon dioxide gas of 70 mm of mercury. above.
For prevention of pneumonia and atelectases carry out percussion massage, banks and physiotherapeutic procedures are useful.
At early children's age in connection with age imperfection of functions of kidneys introduction of large amounts of liquids, especially salt solutions, dangerously.
Features of the postoperative period at patients of advanced and senile age
Key feature of Pct at patients aged after 60 years is its rather heavier current that is caused by depression of function of respiratory and cardiovascular systems, decrease in body resistance to an infection, deterioration in regenerative abilities of fabrics. Quite often operational injury leads to an aggravation explicit or latentno the current accompanying pathology — a diabetes mellitus, diseases of kidneys, a liver, etc. With age the vital capacity of lungs decreases, maximal ventilation of lungs considerably decreases, drainage function of bronchial tubes is broken that promotes emergence of atelectases (see. Atelectasis ) and pneumonia (see. Pneumonia ). In this regard are of particular importance respiratory and to lay down. gymnastics, massage, early activation of patients, purpose of bronchial spasmolytics. In the first 3 — 5 days after operation apply periodic inhalations of nitrous oxide with oxygen by means of the narcotic device of a discontinuous flow (see. Inhalation anesthesia ). This action promotes removal of a pain syndrome, good expectoration and unlike drugs the respiratory center does not oppress. Due to the phenomena which are often noted at elderly people atherosclerosis (see), cardiosclerosis (see) and restriction of compensatory opportunities of a cardiac muscle by it surely appoint cardiac glycosides. For improvement of a coronary blood-groove at patients with hron, coronary heart disease (see) Intensainum, Isoptinum, vitamins of group B, nicotinic to - that, etc. are shown.
Because of considerable age changes of coagulant system of blood at patients of this group hypercoagulation prevails, edges becomes more expressed after operations, especially concerning malignant new growths and acute inflammatory processes of abdominal organs. Preventive actions are treatment of heart failure, thrombolytic therapy and early activation of patients.
In prevention of pulmonary, cardiovascular and tromboembolic postoperative episodes the essential role was got by long peridural anesthesia (see Anesthesia local), thanking a cut at patients a high physical activity, adequate external respiration and good orientation remains.
Decrease in compensatory opportunities of the growing old organism defines need of more frequent research of acid-base equilibrium and electrolytic balance for timely and their adequate correction.
In connection with decrease in kislotnofermentativny and motor function of a stomach and intestines purpose of the digestible, sparing and high-calorific diet is shown to elderly people in Pct.
Patients of senile age have a suppuration of an operational wound more often, a cut quite often proceeds without characteristic signs of an inflammation that demands more careful control of a wound. At suppurations widely apply methyluracil and pentoxyl, and locally, in a wound — proteolytic enzymes.
Regenerative features of fabrics at elderly people are reduced therefore seams at them are recommended to be removed on 9 — the 10th days, and at onkol, patients — on 11 — the 16th days after operation.
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T. P. Makarenko; B. H. Alekseev (oft.), 3. X. Gogichayev (Ur.), O. I. Efanov (fi-zioter.), V. P. Illarionov (to lay down. physical.), I. V. Kliminsky (Abd. hir.), R. N. Lebedeva (cards, hir.), N. V. Menyaylov (injuries.), W. A. Michelson (it is put. hir.), E. B. Sirovsky (neyrokhir.), M. A. Tsivilko (psychiatrist.).