PERIOPERATIVE COURSE FOR THE RESIDENTS

PERIOPERATIVE:
AN INTRODUCTION

TIM PERIOPERATIF

DEPARTEMEN OBSTETRI-GINEKOLOGI
FAKULTAS KEDOKTERAN UNIVERSITAS INDONESIA
2014
 Basic T1 T2 T3 T4
T1A T1B T2A T2B T3A T3B T4A T4B

Kuliah basic MRCOG

part 1 Diskusi, belajar mandiri, e-learning
Basic skill Bedside teaching
APN, PONED, APK, CTU, RN,
Manajemen laktasi, PI, CMBM Clinical tutorial, Morning report, Case parade

Basic surgical Basic ultra- Basic ultra- Induksi chief

skill 1 sound (Obs) sound (Gyn) Clinical training skills
Basic CTG Basic surgical Clinical governance

Vaginal skill 2 Ethico-medico-legal

WORKSHOP

surgery 1 Clinical and medical

audit
Emergency Perioperative Vaginal
medicine 12 roles of medical
Team App surgery 2 teacher
Induksi Obstetric Gynecology CEEBM
obstetrik surgical skill surgical skill Leader in emergency
team
Induksi
Family financial
ginekologi management
Why should we learn about
perioperative?
Case illustration
Mrs. A. 27 years old
G2 P1 term pregnancy
Sent from midwives due to
antepartum bleeding
On admission:
Apathies, BP 90/60mmHg, PR
110x/min, RR 24x/min, no fever
Pale conjunctiva
Uterine tenderness
No fetal heart rate, EFW 2700 gr
No cervical opening, no vaginal
bleeding

Laboratory results:
Hb:6 Ht:18 L:15,000 Tr:70,000
pT:1.5xC, aPTT 2.5xC, Fib:150
D-dimer:1500
RBG: 180
Blood group: O+
Ureum: 80, Creatinine: 1.5
Albumin 2.8
UL: protein +2
 Perioperative

• Early warning system

•
Pre-
• Surgical risk Intra-
• Surgical procedure Post-Enhance recovery
after surgery
• Anesthetic risk
operative • Anesthetic procedure
operative operative
• Wound care
• Discharge plan

Basic knowledge
Anatomy Physiology Pathology
PROBLEMS WHICH MAY OCCUR DURING
PERIOPERATIVE PERIOD

Brain ?
Respiration ?
Cardiovascular ?
Liver ?
Kidneys ?
Pancreas ?
Haemostasis ?
Nutrition ?
Immunology ?
 OXYGEN DELIVERY

DO2 = CO x Hb x SaO2 x 1.34

Airway
Breathing Oxygenation P aO 2
CaO2
Hemoglobin Carrying capacity S aO 2 DO2

Delivery Cardiac Output Flow rate / Ht

Tissue
Systemic circulation
perfusion

PRELOAD AFTERLOAD
 AEROBIC METABOLISM

O2

Glu O2
SYOK

George. ICU without walls, 2014

Respiratory function
Heart is an
essential organ
for oxygen
delivery
 Fluid management

Characteristics of the blood

Blood volume
Depends on weight and age
Coagulation (intrinsic pathway) Coagulation (extrinsic pathway)

Factor XII TFPI Factor VII

Factor XI
TF

endothelium
Thrombogenic
Factor VIII Factor IX TM
Factor V Factor X

Prothrombin Thrombin
TF = Tissue Factor
TM = Thrombomodulin
Fibrinogen FIBRIN- TFPI = Tissue Factor Pathway Inhibitor
PLATELET
Protein S THROMBI Plasmin Plasminogen

A Protein C Protein C
a22PI
TM
Thromboresistant

TF tPA

endothelium
endothelium

Activated

PAI-1

Natural anticoagulant pathway Fibrinolytic pathway

Regulation of fluid balance

Listen to what urine says …

PROGNOSTIC VALUES FOR
HIGH RISK PATIENTS
Blood volume
Blood pressure
Cardiac output
Heart rate
O2 delivery
Urine
output O2 consumption
Metabolic Stages Following Trauma

Day Phase Characteristics

1-2 Ebb (or Shock) Low metabolism
Extremely high metabolism
2-25 Catabolic Flow Extremely high nitrogen consumption
Redirection of protein synthesis
Lower metabolism
25+ Anabolic Flow
Return to normal protein synthesis pattern
Pain sensation could affect
adverse biological effects
Change in gastric Plasma volume
emptying time increases by 40-50%

Relax esophageal RBCs increase only by

spinchter and gastric 15-20%
compression
Clotting activities
Glomerular filtration increases
rate increase
Cardiac output
Renal plasma flow increases by 30-40%
increase
Aortocaval compression
Thyroid binding
globulin increase Blood pressure
decreases by 8-20%
Total and free cortisol
increase Increase ventilation

Mild diabetogenic High O2 consumption

state
Increase Tidal volume
Physiological changes during pregnancy
PREECLAMPSIA
Enjoy the course…