CLASSIFICATION OF MEDICAL CONDITIONS.ppt
- 1. KMTC LECTURE SERIES CLASSIFICATION OF SURGICAL CONDITIONS
- 2. Surgery is classified according to whether it is vital to life, necessary for continued health or desirable or personal reasons. It can be classified into: Emergency surgical conditions Urgent surgical conditions Elective surgical conditions
- 3. Emergency Surgical conditions It refers to unpredictable events that result in the need for immediate surgical attention. Also called emergency surgeries.E.g. Injury from An automobile A violent assault A fire
- 4. A sudden change in chronic medical problem such as a perforated peptic ulcer or a strangulated hernia. Emergency cases typically involve treatment of: Gunshot and stab wounds Fractures of the skull and other major bones
- 5. Head injury with other intracranial hematoma and lateralizing signs Multiple injuries Severe eye injuries Acute airway obstruction e.g. chocking
- 6. Acute abdomen: presenting as acute onset severe pain in the abdomen area for which immediate surgery might be the remedy. i. Acute appendicitis ii. Intestinal obstruction iii. Intussusception iv. Testicular torsion
- 7. Urgent surgical conditions It refers to cases in which an operation is vital but can be postponed for a few days.E.g. Cancer of a vital organ Acute cholecystitis Acute diverticulitis Kidney stones Injury with minor bone fracture
- 8. Elective surgical conditions It can be classified as Required Selective Optional
- 9. Required Elective surgery It includes physical ailments that are serious enough to need corrective surgery but that can be scheduled weeks or months in advance.
- 10. Selective Elective surgery This covers a broad range of conditions that are of no real threat to the immediate physical health of the patient, but nevertheless should be corrected by surgery in order to improve comfort and emotional health.E.g. cleft lip and cleft palate, removal of certain cysts and benign fatty or fibrous tumours.
- 11. Optional Elective surgery This includes operations that are primarily of cosmetic benefit. E.g. removal of warts and other non malignant growths on the skin, blemishes on the skin and cosmetic surgery undertaken for cosmetic reasons.
- 12. MEDICAL CONDITIONS THAT AFFECT SURGICAL TREATMENT
- 13. There are a number of medical conditions that can affect the outcome of surgical treatment. These are : Diabetes mellitus Anaemia Haemoglobinopathies
- 14. Bleeding disorders Varicose veins, leg swelling and DVT Hypertension Obesity Jaundice Thyrotoxicosis
- 15. Hypothyroidism Arrhythmias Adrenal insufficiency Cushing’s syndrome
- 16. Diabetes Mellitus Blood sugar levels must be under control before surgery. Uncontrolled diabetes can slow the healing of a surgical wound It also predisposes one to post operative infection
- 17. Surgery can cause increased stress to the body and higher blood sugar. Insulin dose may need to be adjusted. Diabetics patient are at specific risk from general anaesthesia and surgery due to the following reasons:
- 18. Certain complications of diabetes are associated with a higher post operative risk Stress(e.g. surgery, trauma and infection) cause increased production of catabolic hormones which oppose the action of insulin, hence making diabetic control more difficult.
- 19. General anesthesia, surgery ,deprivation of oral intake and post operative vomiting disrupt the delicate balance between dietary intake ,exercise(energy utilization) and diabetic therapy. Diabetic ketoacidosis may cause an elevated leucocyte count and raised amylase level which may confuse the diagnosis of acute abdomen..
- 20. DKA may sometimes present with abdominal pain Diabetic patients are at greater risk of hospital acquired infections.
- 21. Diabetes mellitus….. Perioperative management of insulin dependent diabetics: Establish good diabetic control before operation Give soluble insulin as a continuous intravenous infusion during the operative period
- 22. Give an infusion of dextrose throughout the operative period to balance the insulin given and to make up for lack of dietary intake Add potassium to the dextrose infusion Monitor blood glucose and electrolytes frequently throughout the operative and early post operative period.
- 23. Diabetics controlled on oral hypoglycaemic agents: Maintain on short acting sulphonylureas such as glipizide(omit dose on the day of operation) Patients on long acting drugs such as metformin should be changed to short acting sulphonylureas several days before the operation.
- 24. If this fails to provide adequate control, an insulin regimen can be used.
- 25. Diabetics controlled by diet alone: These do not require special preoperative measures as they do not become hypoglycaemic and blood glucose rarely drifts above acceptable levels.
- 26. Anaemia Anaemia increases the risk of cardiac and wound complications during surgery. Full blood count should be done before surgery. Haemoglobin level must be checked.
- 27. Haemoglobinopathies Patients with sickle cell disease and beta thalassaemia have a high operative morbidity and mortality They require intensive perioperative management with particular attention to avoiding hypoxia,infection,acidosis, dehydration and hypothermia.
- 28. Bleeding Disorders 1. Thrombocytopenia 2. Haemophilia 3. Von-Willebrands disease Can cause uncontrolled bleeding intra- operatively.
- 29. Most surgical bleeding problems are caused by : Poorly controlled anticoagulant therapy Liver disease Aspirin therapy Vitamin k mal-absorption such as in obstructive jaundice
- 30. Varicose Veins, Leg Swelling, DVT Surgery and post-operative immobility increases the risk of DVT Blood clots can be dislodged leading to embolism into the lungs
- 31. Hypertension Blood pressure control is necessary before surgery High blood pressure control can lead to excessive haemorrhage during surgery
- 32. Obesity Overweight and obese patients are at increased risk of medical and surgical complications including wound infections,pneumonia,blood clots and heart attack. Losing weight before surgery would improve the outcome of surgery.
- 33. Surgical complications of obesity Cardiopulmonary complications such as cardiac failure and chest infections Wound complications such as infections, wound dehiscence and burst abdomen Venous thromboembolism-increased risk of deep venous thrombosis pulmonary embolism
- 34. General anaesthetic complications Anatomical problems e.g. intravenous canulae are difficult to insert and intubation is more difficult. Clinical signs of dehydration and hypovolaemia are more difficult to elicit. Physiological problems: metabolic issues such as altered distribution of drugs.
- 35. Predisposition to various medical disorders Hypertension Ischaemic heart disease Type 2 diabetes Gallstones Gout
- 36. Operative difficulties Operations take longer time to perform because of difficult access and vital structures obscured by fat This leads to a higher incidence of anesthetic and surgical complications, particularly involving the wound.
- 37. Problems of manual handling of patients who are markedly overweight Weight and size limitations of standard equipment,e.g. CT scanners, operating tables, beds Risks to staffs involved in lifting and handling
- 38. Jaundice Jaundice delays post operative wound healing Vitamin K malabsorption in obstructive jaundice can lead to excessive bleeding.
- 39. Thyrotoxicosis Thyroid and non thyroid surgery for a patient with uncontrolled thyrotoxicosis carries a risk of thyrotoxic crisis attendant high mortality It can increase the risk of cardiac complications Hyperthyroidism must be controlled before surgery.
- 40. The patient must be rendered euthyroid before operation using antithyroid drugs and beta blocking agents Non selective beta blocking agents rapidly control the cardiovascular effects of thyrotoxicosis and be used for urgent perioperative preparations.
- 41. Hypothyroidism These patients have moderate risk when undergoing surgery. They are more sensitive to CNS depressants have decreased cardiovascular reserve and are also susceptible to electrolyte disorders such as water retention.
- 42. If there is clinical suspicion of hypothyroidism, operation should be delayed or postponed until oral replacement is initiated.
- 43. Arrthmias A problem with the rate or rhythm of the heartbeat. Tachycardia Bradycardia Irregular heart beat Can lead to operative and post operative complications
- 44. Adrenal Insufficiency Patients with adrenal insufficiency must be give steroid cover during the perioperative period. Intravenous injection hydrocortisone 25-50mg prior to operation and 50mg daily until recovery.
- 45. Lack of additional adrenal response to the stresses of surgery or trauma may cause acute postoperative cardiovascular collapse with hypotension and shock ( Addisonian crisis)
- 46. Cushing’s Syndrome This result from excess secretion of cortisol Long term steroid therapy for conditions such as rheumatoid arthritis or asthma is the most common cause of cushingoid features Cushingoid patients suffer are predisposed to Hypertension Hyperglycaemia
- 47. Poor wound healing Infection Peptic ulceration
- 48. THE END