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An Internist’s Illustrated Guide to Gastrointestinal Surgery - part 6

Không đóng trình duyệt đến khi xuất hiện nút TẢI XUỐNG Tải xuống

Nó không phải là hiếm gặp bệnh nhân dùng thuốc chống đông máu cho một loạt các điều kiện. Ví dụ phổ biến nhất là bệnh nhân đang dùng coumadin rung tâm nhĩ hoặc huyết khối tĩnh mạch sâu hoặc thuyên tắc phổi. | 166 Kozol It is not uncommon to encounter patients taking anticoagulant medications for a variety of conditions. The most common example would be patients taking coumadin for atrial fibrillation or for deep venous thrombosis or pulmonary embolism. In such cases the physicians who care for the patient must determine a perioperative plan for the patient s anticoagulation. If the indication for the anticoagulation is questionable the anticoagulant may be stopped indefinitely. If however anticoagulation is a necessity as in protection of a prosthetic heart valve the following procedure is frequently followed. The patient is instructed to stop taking coumadin 1 or 2 d prior to admission. The patient is admitted the day prior to surgery and is given intravenous-iv-heparin. The purpose of this regimen is to convert from anticoagulation which is slow to reverse coumadin to anticoagulation which is rapidly reversible heparin . The intravenous heparin is then stopped about 2 h prior to surgery. The heparin is restarted 4-8 h postoperatively depending on the magnitude of the operation. Finally the patient resumes his her coumadin prior to discharge. PROCEDURE Elective colon surgery requires bowel preparation. The goal of bowel preparation is to diminish the bacterial load logarithmically. The mechanical portion of the prep is accomplished by oral laxatives which have replaced old-fashioned enema preps. The oral prep may be performed with a high volume solution of polyethylene glycol plus electrolytes with Fleets phospho-soda solution or with magnesium citrate. Additional antimicrobial preparation is achieved via the oral intake of poorly absorbed antibiotics such as neomycin and erythromycin base. Preoperative bowel preparation has lowered infectious complications of colon surgery from double-digit rates to singledigit rates. As with many operations a picture or a diagram may be worth a thousand words for understanding the operation. The following description will allow .