CLASSIFICATION OF MEDICAL CONDITIONS.ppt

Surgery

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-Willebrandsdisease
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