PREOPERATIVE PERIOD

From Big Medical Encyclopedia

PREOPERATIVE PERIOD — the period from the moment of arrival of the patient in surgical department of a hospital prior to carrying out operation, during to-rogo is carried out by a complex of the actions directed to training of the patient for operation.

Pct conditionally divide into 2 stages: diagnostic (specification of the main diagnosis, detection of associated diseases, studying of a condition of functions of vitals and systems, establishment of indications to operation and determination of necessary volume of intervention) and ethane of direct preoperative preparation (carrying out to lay down. actions for the purpose of transfer of basic process in an optimum phase, treatment of associated diseases, correction of disturbances of functions of vitals and systems). All actions of preoperative preparation are directed generally to as much as possible to reduce danger of operation and to warn or reduce weight of possible postoperative complications. Also training of the surgeon, anesthesiologist and other participants of operation, preparation is provided surgery block (see) and surgical tools (see. Surgery ).

Depending on complexity of all preoperative preparation, features patol, process, urgency of operation duration of all Pct happens various. At the diseases demanding an urgent operative measure (a ruptured ulcer of a stomach, impassability of intestines, an acute appendicitis, the restrained hernia, etc.) when bystry development patol, process creates direct threat for life of the patient, the Pct is as much as possible reduced, operation is made urgently. At onkol. sick Pct shall not be long in connection with steady development patol, process. At chronic inf. diseases (hron. suppuration of lungs, hron. osteomyelitis, hron. pleurisy, etc.), demanding prolonged preliminary treatment, Pct can be long.

In practice of modern surgery the tendency to reduction of Pct because of danger of an intrahospital infection, as a rule, resistant to widely applied antibiotics is observed (see. Intrahospital infections ), and threats of infection with it of preoperative patients. In some cases the general preparation for surgery is carried out in specialized departments — endocrinological (at a thyrocardiac craw), hematologic (at diseases of blood), cardiological (at heart diseases), therapeutic, etc. Collaboration of the surgeon and specialist therapist provides high precision of diagnosis, the best training of the patient for operation and promotes rational use of bed fund of surgical departments.

Before operation the doctor makes short epicrisis (see), in Krom proves need of operation, defines (presumably) its character and volume, a look anesthesia (see) also does necessary preoperative appointments. Take the receipt on consent to operation from the patient; the receipt on consent to operation at the child, and also the patient deprived of consciousness or deranged is taken from relatives, at their absence the relevant decision is introduced in an epicrisis consultation (see).

The general actions for training of patients for planned operation

Preparation of a nervous system

Almost each patient before operation is in a condition of nervous tension. Especially excitable persons have a fear of pains, alarm for the result of operation, a perezha of a vaniye concerning the nature of a disease can lead to an overstrain of a nervous system (see. Neurosises ), in this connection their cold sweat, dryness is observed in a mouth, a hyperadrenalemia, etc. Carry out careful prevention of these phenomena to Pct that at the same time serves also as prevention operational shock (see) and some other possible complications during operation.

The patient shall be protected from everything that maintains his hypererethism and promotes a sleep disorder. For this purpose appoint analgesic means (see), tranquilizers (see), hypnagogues (see), electrosleep (see). When the patient has painful questions and heavy experiences, curative value acquires the calming word of the doctor, the sensitive, attentive relation of all personnel (see. Deontology medical ).

The large role is played by the thought-over organization of work in surgical department, at a cut contacts of the patients expecting operation with the patients who just transferred it whose type, the groans, vomiting which got wet with blood of a bandage can make a painful impression are excluded. In practice of modern surgery this problem is resolved thanks to the organization of intensive care units (chambers) in which patients are in the first days after operation.

For a nervous system prenarcotic premedication has guarding value (see. Anaesthesia ), appointed by the anesthesiologist. As a result of it the nervous tension just before operation sharply decreases; at the night of the patient sleeps, to the operating room comes on a wheelchair in a drowsy state.

Preparation of cardiovascular system and normalization of composition of blood

At normal activity cardiovascular system (see) small and average operations on weight make without special training of the patient. At insignificant weakening of function of cardiovascular system (pallor of skin, tachycardia, decrease in the ABP, dullness of cordial tones) without the phenomena of organic changes usually there is sufficient an appointment within several days in Cordiaminum or one of cardiac glycosides and intravenously on 20 — 40 ml of 40% of solution of glucose to addition of 3 ml of 5% of solution ascorbic to - you; preparation for big operations is expressed in longer holding the listed actions. At organic lesions of heart and vessels add the appropriate special means — hypotensive, vasodilating, spasmolytic.

Considering that big operations are usually connected with considerable blood loss (see), before them do single or repeated hemotransfusion (see) on 200 — 250 ml. Hemotransfusion is especially important at anemia since patients in whose blood the hemoglobin content is lower than 58 — 66 g/l badly undergo an operation, to their thicket develop and heavier complications as proceed during operation (shock, an anoxemia, etc.), and in the postoperative period (the slowed-down angenesis, an infection of an operational wound, discrepancy of seams, etc.). The patient with anemia at first with repeated hemotransfusions raise a hemoglobin content to 100 — 108 g/l, improve function of the hemopoietic bodies and only after that make operation, providing hemotransfusion also in time and after it.

Planned operations are not appointed in the period of periods since these days the raised bleeding and decrease in immunobiological reactivity of an organism is noted. For prevention thromboses (see) and embolisms (see), especially at patients with varicosity (see), phlebitis (see) or thrombophlebitis (see) in the past and the present, and also at the cancer patients who are usually predisposed to thromboembolisms, in Pct investigate the level of a prothrombin and in case of its increase appoint anticoagulants (see); carry out also to lay down. physical culture, bandaging of the lower extremities, etc.

Preparation of a respiratory organs

Preparation of a respiratory organs is directed to reduction of probability of development of the postoperative pulmonary complications which are found quite often and leading sometimes to a lethal outcome (see. Postoperative period ). Inflammatory processes of upper respiratory tracts and bronchopulmonary system (rhinitis, sinusitis, acute and hron, bronchitis, pneumonia, etc.) serve as a contraindication to planned operations and are subject to treatment in Pct. At the same time are widely used expectorants (see), antibiotics, sulfanamide drugs (see), physiotherapeutic procedures, inhalations, etc. At patients with emphysema of lungs (see) p pneumosclerosis (see) for improvement of passability of a trachea and bronchial tubes and increase in a respiratory excursion of a thorax carry out medicamentous therapy (expectorants, Theophedrinum, an Euphyllinum), to lay down. bronkhoskopiya (see) using antiseptic agents (see) and proteolytic enzymes (see. Peptide-hydrolase ), oxygen therapy and a complex a dykhatel ache gymnastics. For prevention bronchitis (see), atelectasis (see), atelectatic pneumonia (see) and other pulmonary complications before operation (especially on bodies of a chest or abdominal cavity) it is necessary to teach the patient correctly and to deeply breathe and cough up a phlegm.

Preparation of the alimentary system

carry out sanitation To Items oral cavities (see) for the purpose of elimination of the centers of the dozing infection and prevention of such postoperative complications, as parotitis (see), stomatitis (see), glossitis (see), periodontosis (see), etc.

Clarification went. - kish. a path before operation promotes prevention of an endogenous infection. However frequent use of purgatives leads to decrease in a tone of an intestinal wall, weakening of a vermicular movement, development of a meteorism. Owing to meteorism (see) the diaphragm rises that complicates lung ventilation and promotes development of postoperative pneumonia. Against the background of preoperative starvation reception of laxatives aggravates disturbance of exchange processes: in fabrics the connections causing shift of pH of the environment in the acid party and causing a picture of heavy collect intoxications (see) with vomiting, a meteorism, an oliguria, etc. Therefore in the course of preoperative preparation it is necessary to resort to purpose of purgatives and starvation only according to special indications, hl. obr. at a large intestine operations. As a rule, on the eve of operation appoint a cleansing enema; in case of inefficiency give an enema repeatedly.

In Pct events for elimination of a helminthic invasion are held if in Calais the patient eggs a worm were found. It is especially important at an ascaridosis since ascarids after operation can leave p to get with an emetic masses into airways, becoming the reason of asphyxia, can cork bilious ways, causing development of jaundice, to get through seams of an anastomosis into an abdominal cavity, causing development of peritonitis etc.

For improvement of function of a liver it is necessary to create before operation in it considerable stocks of a glycogen that at the exhausted and weakened patients usually is reached by carrying out a course of intravenous injections of 40% of solution of glucose with ascorbic to - that. In this regard there has to be strictly motivated a restriction of meal before operation. Purpose of methionine, Sireparum, cyanocobalamine (polyneuramin 12 ) also contributes to normalization of function of a liver.

Preparation of kidneys

At any operation increases a functional load on kidneys of the patient in connection with introduction to an organism of various drugs and a large amount of salt solutions, hemotransfusion and receipt to blood of elements of the destroyed fabrics from area of an operational wound. Therefore in Pct carefully investigate function of kidneys for the purpose of correction of the revealed deviations (see. Kidneys ). Close interrelation of a liver, kidneys (see. Hepato-renal syndrome ) and cardiovascular system causes the necessity of complex assessment of a condition of these systems and their compensatory reactions.

Prevention of suppuration of an operational wound

At detection at the patient of purulent diseases of skin (a furunculosis, a pyoderma, pustulous rash, eczema, grazes and scratches with inflammatory reaction, etc.) operation is postponed until treatment of inflammatory process. Reveal also possible centers of the dozing infection — signs of recently postponed purulent diseases (as in the first weeks after visible healing of the inflammatory center microbes can nest still in limf, ways not only close, but also in the areas of a body remote from it), old hems and commissures. An operational injury, weakening protective forces of an organism, can stimulate the dozing infection that leads to suppuration of an operational wound and even to sepsis (see). Danger increases when at operation the center of the dozing infection or nearby fabrics are mentioned directly. Sometimes apply a method of provocation to detection of the dozing infection: influence hems electric field of UVCh and UV rays, carry out massage, mud applications, etc. In the presence of the dozing infection at the patient body temperature increases, reddening and a swelling in the field of hems are observed, the local leukocytosis increases. For prevention of outbreak of an infection before operation in the field of hems (especially at positive test on provocation) antibiotic treatment and stimulation of immunobiological forces of the patient with specific and nonspecific means are shown.

Preventive use of antibiotics is justified also before the operations interfaced to risk of massive bacterial pollution or when the volume and injury of the forthcoming operation obviously exceed possibilities of natural mechanisms of antibacterial resistance of an organism: appoint anti-bio tics of a broad spectrum of activity, first of all semi-synthetic penicillin (see) and cephalosporins (see).

Also stimulation of immunobiological responses, especially at patients whose condition promotes development of microflora (the weakened, exhausted, anemic patients belongs to measures of prevention of a postoperative surgical infection; excessively full patients with the broken lipometabolism; patients, the Crimea it is necessary to undergo a big operation with extensive damage of fabrics, etc.). Treat methods of stimulation of immune responses and processes of regeneration: hemotransfusion, introduction of specific stimulators (staphylococcal anatoxin, gamma-globulin, anti-staphylococcal plasma); nonspecific means and methods of stimulation of processes of regeneration (methyluracil, pentoxyl, pyrogenal, LFK, physiotherapeutic procedures, etc.), saturation of an organism of the patient with vitamins (In 1 , In 12 , With, To, etc.). Same normalization of a metabolism, first of all proteinaceous and water and electrolytic, broken especially at a stenosis of peloric department of a stomach, a tumor of a gullet, impassability of intestines, hron promotes. suppurative processes and at other diseases which are followed by vomiting, a diarrhea, anorexia. Normalization of proteinaceous structure of a blood plasma in such cases is reached by repeated hemotransfusions, injection of plasma, proteinaceous hydrolyzates of amino-acid mixes, the balanced food, etc.; the water and electrolytic balance is recovered injection of solutions of electrolytes (see. Infusional therapy ).

It is extremely important to exclude in the preoperative period the fact of finding of the patient in an incubation interval of any general inf. diseases, a cut the condition of the patient can sharply worsen and promote development in it of a purulent infection. It is also necessary to consider existence of associated diseases at which regenerative abilities and immunobiological reactivity of an organism decrease. The diabetes mellitus belongs to such diseases, in particular, (see. diabetes mellitus ), at Krom operational wounds heal slowly and often suppurate. As preparation for planned operations at patients with a diabetes mellitus by means of glyukozoinsulinovy therapy aim to lower a sugar content in blood to 200 mg of % and below and to liquidate acetonuria (see) for what appoint intravenous administrations of 40% of solution of glucose and the doses of insulin, maximum for this patient. Before an immediate surgery sick diabetes enter 20 — 40 ml of 20% of solution of glucose intravenously and 20 — 25 PIECES of insulin under skin (according to G. A. Ryabov, in the presence of acidosis the need for insulin sharply increases). All sick diabetes before operation appoint a diet with restriction of carbohydrates and fats.

On the eve of operation of the patient takes a bath and changes linen, in the morning in day of operation make shaving of a surgery field, before the operation — processing by antiseptic agents (see. Surgery field ).

The physical therapy

In Pct is appointed for the purpose of a training of vascular and nervous systems, activation of immunobiological and exchange processes in an organism, increases in local resistance of fabrics of a surgery field. For this purpose appoint the general UF-radiation on one of the standard schemes (see. Ultraviolet radiation ), a cut carry out daily or every other day and finish some days before operation.

Stimulation of microcirculation, to a training of vascular and nervous systems is promoted by hydrotherapeutic procedures — bathtubs, souls with gradual fall of temperature or with use of contrast temperatures. UF-radiation and hydrotherapeutic procedures can be combined and combined for simultaneous impact on various physiological processes in an organism.

At functional disturbances from c. the N of page, the increased emotional excitability appoint an aero ionotherapy (see. Aeroionization ), electrosleep (see), calcium - and bromelektroforez on a collar zone (see. Electrophoresis , medicinal). These procedures contribute to normalization of processes of excitement and braking of c. N of page, improve a dream, reduce perspiration, increase resistance of an organism to external influences.

The physical therapy has special value in purulent surgery, traumatology and orthopedics. In the presence of a suppurative focus for its bystry otgranicheniye, removal of hypostasis, reduction of virulence of microflora locally use UVCh-therapy (see), microwave therapy (see), erythematous UF-radiations, electrophoresis of antibiotics. Duration of a course of physical therapy depends on duration of Pct.

By preparation for recovery and reconstructive operations (see. Plastic surgeries ) apply: at cicatricial contractures — ultrasound (see. Ultrasonic therapy ), fonoforez a hydrocortisone, a lidaza in combination with a thermotherapy (see. Thermal treatment ), impulse currents (see); at not accrete changes — magnetic zero high and low frequency (see. Magnetotherapy ), thermotherapy; at change of muscles — electrostimulation of muscles (see. Electrostimulation ) and massage (see).

For prevention of diseases of a bucket-handle graft (see. Skin plastics ) long before hospitalization of the patient in polyclinic conditions the preliminary training of vessels of operational zones by means of local or general hydrotherapeutic procedures with gradual fall of temperature of water, the general UF-radiations and massage can be held. In Pct use ultrasound in pulsed operation and small intensity or irradiate skin of the specified zones with UV rays since suberythema doses. In the presence of ulcers in a zone of skin transplantation for decrease of the activity of microflora, improvement of microcirculation and a trophicity use ultrasound, an electrophoresis of antibiotics, proteolytic enzymes, drugs of zinc, darsonvalization, magnetotherapy, local light bathtubs and UF-radiation in erythema doses.

At identification in an organism of the centers hron, infections carry out their sanitation. So, at hron. tonsillitis, pharyngitis appoint UVCh-therapy, microwaves, ultrasound, radiation by short UV rays, inhalations (see. Inhalation ), at hron. inflammatory diseases of lungs — an aerosoltherapy using antibiotics, proteolytic enzymes, antihistaminic substances, UF-radiation of a thorax an integral flow.

The physiotherapy exercises raise the general tone of an organism, influence c. N of page, normalizing cortical processes and raising compensatory opportunities of an organism. With its help of the patient train full, correct chest (by preparation for operations on a stomach) and phrenic (by preparation for operations on a thorax) in breath, expectoration and the correct turn sideways, to a complex of elementary physical exercises which it will carry out in the first days after operation.

LFK appoint all patient prepared for planned operation. In particular, at patients with hron. purulent diseases of lungs to lay down. the gymnastics promotes removal of a phlegm and desintoxication of an organism; at patients with heart diseases at various degree of a circulatory unefficiency she pursues the aim of improvement of all noncardiac factors of circulation.

A contraindication to LFK is the general serious condition of the patient, a possibility of bleeding, existence of acute inflammatory process with high temperature, sharp pains in the area patol. process.

Complexes of physical exercises of LFK are based depending on the nature of a disease and alleged operation, is more often by the principle of alternation of breathing exercises of static and dynamic character with emphasis on the extended exhalation with the all-developing exercises, is preferential for muscles of top and bottom extremities. At plentiful expectoration so-called drainage exercises are recommended. Exercises apply to muscles of an abdominal wall taking into account degree of a pain syndrome, a possibility of bleeding and other painful manifestations. The majority of exercises are carried out in a prone position, a smaller part — in a standing position or sitting. In a complex usually 9 — 11 exercises, duration of occupation of 10 — 15 min. Krom of occupations under the leadership of the methodologist, are recommended to the patient independent occupations 2 — 3 times a day in which it is necessary to include 3 — 4 breathing exercises.

Fortifying actions

the Patient needing special food it is appointed in Pct depending on features of a disease (see. clinical nutrition ). All other patients receive high-calorific, various, tasty, vitamin-rich food.

Positive impact is exerted by optimal all-hygienic conditions — light, well aired, small (on 2 — 3 beds) chamber, regular walks, etc.

Immediate surgeries most often make Features of training of patients for immediate surgeries concerning injuries (wounds of soft tissues, open fractures of bones, the getting wounds of a breast, a stomach and a skull, the closed internal injuries) and acute surgical diseases (an acute appendicitis, destructive pancreatitis, phlegmonous, gangrenous or perforative cholecystitis, a ruptured ulcer of a stomach or intestines, impassability of intestines, the restrained hernia, etc.). At injuries the nature of training of patients for operation is defined by existence or absence at them bleedings (see), plentiful blood losses (see) and traumatic shock (see). At identification of these complications carry out necessary to lay down. actions then process to an opa the ratsionny field and start operation. In the absence of the expressed blood loss and shock preoperative preparation is limited to careful processing of a surgery field; operation is performed at adequate anesthesia (see) with obligatory control of a condition of functions of vitals and systems.

At repeated bleedings of not traumatic character (at a peptic ulcer of a stomach and duodenum, a varicosity of a gullet and stomach at cirrhosis, tumors went. - kish. a path, erosive gastritis, diseases of blood and the hemopoietic bodies, etc.), the preparation for surgery provides bystry normalization of a homeostasis: recovery of volume of the circulating blood, normalization of its proteinaceous structure and an acid-base state, recovery, and also stimulation of defense reactions of an organism of the patient. A basis of this preparation injection of 5% of solution of glucose, protein hydrolyzates, introduction of cardiovascular means, vitamins, oxygen therapy make transfusion of high doses (to 1,5 l) svezhetsitratny odnogruppny blood in the beginning struyno, then kapelno. At the plentiful not stopped bleeding jet hemotransfusion (see) begin just before operation and continue but a measure of need in time and after it. At the bleeding connected with diseases of blood and the hemopoietic bodies are carried out additional to lay down. the measures caused by specifics of a disease (see. Blood ).

The group of patients with acute surgical diseases is very various on the nature of processes and weight of the state which is sharply worsening at overdue arrival of patients in a hospital. The patient with an acute appendicitis, the restrained hernia, the ruptured ulcer of a stomach and duodenum which came to hospital during the first hours after a disease, preoperative preparation is usually limited to premedication and processing of a surgery field. At overdue arrival of such patients when complications already developed, the main and the most dangerous of which is peritonitis (see), at first are carried out to lay down. the actions directed to fight against an infection (introduction of antibiotics), intoxication (hemotransfusion, injection of blood-substituting liquids, etc.), respiratory and cardiovascular disturbances. Patients with destructive forms of pancreatitis and cholecystitis, impassability of intestines, etc. usually arrive in very heavy sos thawing — with intoxication (see), the reduced ABP, frequent pulse, the expressed anoxemia (see. Hypoxia ), severe pains, dehydration (see Dehydration of an organism) etc. By preparation them to an immediate surgery (and also in time p after operation), vigorous measures for fight against these complications shall be taken.

Features of training of patients for the most frequent operations

the Preparation for surgery concerning a diffusion toxic craw. In Pct at these patients under the influence of nervous tension symptoms can sharply amplify thyrotoxicosis (see) — irritability, frustration of cardiovascular system (including tachycardia), sleeplessness, disbolism, etc. During operation (most often a subtotal strumectomy) a large number of Thyreoidinum comes to blood that strengthens the phenomena of a thyrotoxicosis which proceed also in the postoperative period. These circumstances considerably increase operational risk and demand a careful research (especially conditions of cardiovascular and nervous systems, standard metabolism) during preoperative training of patients (see. Craw diffusion toxic ).

Patients are placed in small chambers, provide them a quiet situation, an every possible shchazheniye of mentality; by means of hypnagogues try to obtain good after-dinner p a night dream. The milk and vegetable diet with restriction of meat is appointed. Good appetite of the patients (who are usually suffering from the raised metabolism) should be satisfied as concerning quantity, and tastes of food. At heavy and a moderately severe thyrotoxicosis treatment is shown to patients by microdoses of iodine (solution of Lugol from 3 to 15 drops 3 times a day, mercazolil on 0,004 g 3 times a day). In 7 — 8 days of treatment by iodine conduct a repeated research. At improvement of a state (decrease in pulse rate, reduction of excitability, decrease in standard metabolism) 4 — 6 more days continue to prepare. In the absence of improvement treatment by iodine is cancelled, appoint a bed rest, bromides, neurosin (on 0,2 — 0,5 g 3 times a day). After that patients operate.

At patients with the expressed hyperphrenia some surgeons with success apply ganglioblokiruyushchy means (see) or antipsychotic drugs (etaperazin, aminazine, etc.), antihistamines (Dimedrol, etc.). The drug which had favorable effect at trial giving is appointed in 2 days prior to operation and applied within 3 — 4 days after it. Hemotransfusion, plasmas, injection of a reopoliglyukin, 40% of solution of glucose with ascorbic to - that is shown to the weakened, exhausted patients and insulin (at the rate of 10 PIECES of insulin on 25 g of dry glucose), vitamins of group B.

Preparation for operations on a liver and bilious ways

in the presence at the patient of the elevated temperature which is especially followed by jaundice, some days before operation appoint antibiotics of a broad spectrum of activity. At long (more than 7 — 10 days) obturatsionny to jaundice (see) and a high bilirubinemia danger of operation considerably increases in connection with possible development of a liver failure or a hepatocerebral syndrome (see. Hepatocerebral dystrophy ). Besides, lack of bile in intestines leads to a lack of an organism of phthiocol which in these conditions is not soaked up from intestines and is almost absent in blood of a portal vein. In this regard development by a liver sharply decreases prothrombin (see) coagulability of blood also goes down. At decrease in a prothrombin of blood lower than 40% are observed hemorrhages, bleeding from wounds and mucous membranes.

At a preparation for surgery of patients with obturatsionny jaundice carry out a complex to lay down. - the prof. of actions including daily injection of 1 — 1,5 l of 5% of solution of glucose from 20 — 30 PIECES of insulin, Haemodesum, solution of sodium salts, potassium, calcium; transfusion of small doses (100 — 150 ml) of blood (it is better svezhetsitratny), injection of albumine, native plasma; introduction ascorbic to - you, vitamins of group B, Vikasolum, Sireparum, cardiovascular means; carrying out forced diuresis (see).

Preparation for operations on a stomach

At the patients having cancer or stomach ulcer, especially with the phenomena of a pyloric stenosis is noted the expressed deficit of volume of the circulating blood and components of blood against the background of proteinaceous insufficiency, and also disturbance of all types of exchange. Repeated hemotransfusions (on 250 — 300 ml), intravenous injections of 5% of solution of glucose, isotonic solutions of sodium chloride, salts of potassium, sodium, calcium, proteinaceous blood substitutes, drugs of fatty emulsions are necessary for a korrigirovaniye of these deviations (in total to 2 — 3 l a day).

At a pyloric stenosis and the lowered contents salt to - you in a gastric juice the patient daily for the night wash out a stomach of 0,25% solution hydrochloric (salt) to - you and appoint inside during food divorced hydrochloric to - that with pepsin.

Depending on a condition of the patient and the nature of the forthcoming operation such preparation continues 6 — 18 days; in the absence of evakuatorny disturbances from a stomach and the expressed exhaustion of the patient of so long preparation it is not required.

On the eve of operation for lunch and a dinner patients are given liquid dishes and sweet tea, for the night give an enema cleansing. In the morning in day of operation with the help of the probe evacuate gastric contents (see. Stomach , operations).

Preparation for operations on colonic and direct guts

Before resection operations of a colon, imposing of an anastomosis, amputation of a rectum by the weakened patient appoint repeated hemotransfusions (on 200 — 300 ml) and injection of infusional environments (5% solution of glucose, isotonic solution of sodium chloride and other blood substitutes) to 2 — 3 l a day. Preparation of intestines is usually begun for 2 days before operation: to the patient allow to eat only liquid food, in the 1st day give laxative in the morning, and give an enema cleansing in the evening; for the 2nd day cleansing give an enema in the morning and in the evening. At the phenomena of partial obstruction of a colon of full clarification try to obtain it by means of repeated cleansing or siphon enemas, light laxatives on what several days usually leave. In the morning in day of operation do not give an enema. Often in 5 — 7 days prior to intervention appoint inside streptocides, antibiotics (Kanamycinum, etc.) for prevention of suppuration of a wound, discrepancy of seams of an anastomosis, peritonitis, etc. (see. Intestines , operations). Before operation on an occasion hemorrhoids (see) per day give laxative; the night before put several cleansing enemas (to pure water).

Preparation for operations on lungs

At cancer of a lung (see. Lungs , tumors) preoperative preparation is directed to improvement of the general condition of an organism, increase in its immunobiological reactivity, elimination of a perifocal inflammation in lungs and sanitation of a mucous membrane of bronchial tubes. At hron, suppuration in a lung hold also events for elimination of purulent intoxication for the purpose of transfer of acute process in a phase of remission.

At defeat by tumoral or suppurative process of a segment or one lung lobe if there is no widespread perifocal inflammation and the expressed intoxication of Pct it can be limited for 7 — 8 days during which once transfuse to the patient blood, pour in 40% solution of glucose with ascorbic to - that and conduct a course of stimulation of immunobiological responses staphylococcal anatoxin. At the suppurative process taking two shares or all lung and also at cancer of a lung with an extensive perifocal inflammation longer preparation for surgery is required, during a cut conduct a course of specific and nonspecific stimulation of immunobiological forces of an organism, appoint repeated hemotransfusions (on 200 — 250 ml) and injections of 40% of solution of glucose with ascorbic to - that, do a repeated fibrobronkhoskopiya with suction of pus and introduction to a gleam of bronchial tubes of solutions of antibiotics or nitrofuran drugs; in especially hard cases antibiotics enter into a suppurative focus or a pleural cavity through a puncture of a chest wall.

Features of the preoperative period at persons of advanced and senile age

Among the people asking for the surgical help are more senior than 60 years many have serious associated diseases, sometimes more dangerous, than that, apropos to-rogo is undertaken operation. Most often atherosclerosis of an aorta, coronary and brain arteries meet, the expressed cardiovascular insufficiency, an idiopathic hypertensia, emphysema of lungs, the pneumosclerosis, bronchitis, dysfunctions went. - kish. path, explicit or latent forms of a diabetes mellitus; also sluggish reactivity of a nervous system, decrease in immunobiological responses and regenerative processes, tendency to fibrinferments and embolisms, weakening of function of the hemopoietic bodies (in this connection they badly transfer blood loss), etc. is noted. There are also features in structure and the course of surgical diseases; at elderly persons more often than at young age, tumors develop, is rather more rare — inflammatory processes; both those and other diseases proceed with indistinct a wedge, symptomatology, edges, as a rule, does not correspond to weight of pathoanatomical changes in sick body. At inflammatory processes (appendicitis, cholecystitis, etc.), the restrained hernia, impassability of intestines usually gangrene and perforation of body with the subsequent inertly current peritonitis quickly enough develop.

All this causes features of Pct at persons of advanced and senile age: at planned operations its diagnostic stage is extended, definition of indications to operation is at a loss, ethane of preoperative preparation becomes complicated and extended. During the training of the patient for planned operation special attention is paid to prevention and treatment of cardiovascular insufficiency (appoints cardiac glycosides in an individual dosage); to improvement of function of breath by elimination of the inflammatory phenomena in lungs and bronchial tubes, carrying out respiratory gymnastics, oxygen therapy, etc.; to prevention of thromboses and embolisms — apply anticoagulants in combination with nicotinic to - that and reopoliglyukiny, to lay down. gymnastics and bandaging of extremities at the strict accounting of indicators koagulogramma (see).

During the definition of indications to operations shall be compared degree of operational risk (weight of alleged operation for the weakened old patient) and danger of waiting tactics (character and features of a course of a surgical disease). At the diseases inclined to recuring (the restrained hernia, the recuring cholecystitis and appendicitis, etc.), it must be kept in mind that at advanced and senile age it is safer to make planned operation (in a phase of remission of a disease) after thorough preoperative training, than emergency (in a phase of an aggravation and complications of a basic disease) when preoperative preparation cannot be carried out fully.

Before an immediate surgery after the diagnostic stage, minimum on time, begin to carry out the essentialest for this patient to lay down. - the prof. of an action who continue also during operation.

Features of the preoperative period at children

In Pct children, the Crimea are coming big and difficult operations, are in surgical department of a hospital. For decrease in risk of intrahospital infection time of stay in a hospital before operation is whenever possible reduced for what many preoperative researches and to lay down. actions are carried out on the basis of children's consultation or policlinic. At simple planned operations children come to surgical department, as a rule, on the eve of operation. The preparation for surgery of newborns with heavy malformations begins quite often already in a maternity home.

Features of Pct at children are caused by hl. obr. mental immaturity and functional inferiority of a row of their systems and bodies.

At children up to three years are usually observed: considerable narrowness of a gleam of bronchial tubes, friability of their mucous membrane and underdevelopment of elastic fibers what tendency to an atelectasis and pneumonia is connected with; the slowed-down coagulability of blood (owing to deficit of phthiocol and a prothrombin) and hypersensitivity to blood loss; imperfection of processes thermal controls (see), leading quite often to hypo - or to a hyper thermal state; the raised susceptibility to an infection, etc.

Before planned operation of the child place in the light, warm, well ventilated chamber. At inspection special attention is paid on a condition of hemocoagulation, exclude a carriage of bacilli of a diphtheritic stick, a hemolitic streptococcus, enteropathogenic colibacillus (see. Carriage of contagiums ), conduct researches on existence anemias (see), gipoproteinemn, hypotrophies (see), rickets (see). The child cannot be operated in a planned order if it has a quantity of erythrocytes less than 3•10 6 in 1 mkl blood, hemoglobin less than 100 g/l, crude protein of plasma less than 50 g/l. If hypotrophy, hron. heart and respiratory failure are symptoms of a basic disease, aim to transfer them to the compensated state.

Mental immaturity and lack of a strong-willed conscientious attitude to ensuring prevention of postoperative complications cause need during the training of children for planned operations to train them in elements to lay down. gymnastics, a postural drainage and to other actions promoting a favorable current of the postoperative period.

In the absence of special indications the bathtub and an enema on the eve of operation to children are usually not done. In day of operation they are not fed, as a rule, (except chest which for 4 — 5 hours before operation milk).

Premedication is appointed by the general anesthesiology principles with the obligatory accounting of features of psychological development of the child. To children from 1 year to 7 years sedative drugs include in premedication in 2 — 3 hours prior to operation, begin to give them to children from 8-year age on the eve of operation. Emotionally labile or repeatedly operated children are entered into an anesthesia in chamber by means of hydroxybutyrate of sodium or Ketaminum (see. Not inhalation anesthesia ).

By preparation for immediate surgeries, an occasion for which at children usually are the acute diseases (especially abdominal organs) proceeding with dehydration, haemo concentration and intoxication, the main objective is fight against intoxication and disturbance of water and electrolytic balance which extent judge on a lab. to data (gematokritny number, an acid-base condition of blood, osmolarity of plasma and quantity in it crude protein, potassium, sodium, etc.). According to the most available methods of a research — to falling of the ABP, tachycardia, decrease in the central venous pressure (it is lower than 20 mm w.g.), oligurias (10 — 15 ml an hour are lower), etc. — quickly estimate also degree of a decompensation of a hemodynamics.

The volume of the solutions entered intravenously before operation define individually (see. Infusional therapy ). At the compensated condition of a hemodynamics enter the calculated quantity of infusional environments of rheological disintoxication action of a pla with inclusion of 10% of solution of glucose and insulin. At a decompensation appoint, in addition to the concentrated solutions of glucose, middlemolecular blood substitutes or drugs of albumine and at the same time for compensation of a metabolic acidosis add solutions of hydrosodium carbonate; administration of vitamins E, groups B is obligatory. Such preparation is continued within 2 — 3 hour. Shorter preparation with inclusion of a transfusion of blood is possible at suspicion of internal bleeding or perforation of a hollow abdominal organ. An obligatory element of preoperative preparation in the emergency surgery at children is sounding of a stomach (see), allowing to avoid the regurgitation in an anesthesia caused by poor development at early age of a cardial press (see. Regurgitation ). Premedication is carried out only with use of the drugs of bystry action administered intravenously or intramusculary.

Preoperative preparation newborns includes creation of an appropriate microclimate of the environment, prevention (or treatment) respiratory insufficiency, a hemorrhagic syndrome and carrying out according to indications of infusional therapy. Providing an adequate microclimate assumes maintenance of a temperature schedule according to degree of a donoshennost (see. Premature children ) and age of the child. In couveuses for premature children relative humidity of air shall be within 90 — 95%, concentration of oxygen — 40 — 80% (depending on degree of respiratory accuracy of a nedost). In treatment of respiratory insufficiency at inborn intestinal impassability regular suction of gastric contents, an intubation of a trachea with the subsequent sanitation of respiratory tracts is important. Before operation preventively apply Vikasolum to prevention of the raised bleeding.

The indication to infusional therapy at newborns are peritonitis, omphaloceles of the big sizes, inborn eventration of intestines, deficit of the weight (weight) of a body (more than 10%) at the birth. Intravenous loading shall correspond to 100 — 125% of volume of age water requirement, and at the states which are followed by respiratory and heart failure — 75%. The structure of the infusional environment depends on the nature of a disease. At an atresia of a gullet use only 10% solution of glucose, at high intestinal impassability — 10% solution of glucose in combination with natriysoderzhashchy solutions (blood substitutes of rheological or disintoxication action) in the ratio 3: 1 (at low intestinal impassability 2: 1). At malformations of a front abdominal wall use solutions of albumine, tinned plasma in volume, the corresponding 1/5 volumes of blood of the patient.


Bibliography:

Bairov G. A. Urgent surgery of children, L., 1973; Questions of preoperative preparation and the postoperative period, under the editorship of V. E. Salishchev, M., 1953; Doletsky S. Ya., Gavryushov V. V. and Akopyan V. G. Surgery of newborns, M., 1976, bibliogr.; E f and N about in O. I. and D z and N and - about in and T. F. Fizioterapiya of dental diseases, page 279, M., 1980; Isakov Yu. F. and Doletsky S. Ya. Children's surgery, M., 1971; To and p the t was eaten also by A. F N. Recovery treatment (physiotherapy exercises, massage and work therapy) at injuries and deformations of a musculoskeletal system, M., 1969; Medical physical culture in surgery, under the editorship of V. K. Dobrovolsky, L., 1976; The multivolume guide to surgery, under the editorship of B. V. Petrovsky, etc., page 211, etc., M., 1962; Preoperative training of patients, earlier treated steroid drugs, Trudy Nauch. - issled. in-that travmatol. and orthoitem, t. 2, page 228, Tbilisi, 1972; Preoperative preparation, the postoperative period, under the editorship of F. P. Vorobyov, Kiev, 1973; The Guide to physical therapy and physioprevention of children's diseases, under the editorship of. A. N. Obro-sova and T. V. Karachevtseva, page 149, M., 1976; Pods V. I., Lokhvitsky S. V. and Misnik V. I. Acute cholecystitis at advanced and senile age, M., 1978; V. I. Pods, Fedorov B. P. and L about x in and the Central Committee and y S. V. Rol of various methods of catheterization of bronchial tubes in a complex of conservative treatment and preoperative training of patients with pulmonary suppurations, Owls. medical, No. 6, page 25, 1966; Hair dryer rank K. M, F e N of the h and N R. M. Is also curve N e D. V c. Use geriatric поливитаминно-аминокислотно-мик-роэлементных drugs for preoperative preparation and postoperative treatment of patients of advanced and senile age, Klin, hir., No. 7, page 62, 1975; Surgery of advanced age, under the editorship of B. A. Korolev and A. P. Shirokova, Gorky, 1974; Blichert-Toft M. Sec-retion of corticotrophin and somatotrophin by the senescent adenohypophysis in man, An assessment based on the hypothalamic-hypophyseal-adrenocortical function and the somatotrophin level in blood in the pre-sence of basal conditions, during Stimulation tests, and in a connection with major surgery, Copenhagen, 1975; Hein H. - A. Analyse der präoperativen Vorbereitung von postoperativ verstorbenen Parientinnen, München, 1972.

B. I. Struchkov; Of A. Bairov (it is put. hir.), A. A. Busalov (to lay down. physical.), O. I. Efanov (fizioter.).

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