مروري ﺑﺮ ﻣﻨﺎﺑﻊ و ﻣﻘﺎﻻت ﭘﺰﺷﻜﻲ ﻣﺴﺌﻮﻟﻴﺖ ﺟﺮاح در ارزﻳﺎﺑﻲ ﻫﺎي ﺑﻴﻤﺎران ﺟﺮاﺣﻲ ﻗﺒﻞ، ﺣﻴﻦ و ﭘﺲ از ﻋﻤﻞ

Review Article Surgeons’ Responsibilities in Perioperative Assessment of Surgical Patients

ﺑﺎ ﺗﻮﺟـﻪ ﺑﻪ ﺑﺎﻻ ﺭﻓﺘﻦ ﻣﺘﻮﺳـﻂ ﺳﻦ ﺩﺭ ﺩﻧﻴﺎ ﻭ ﺑﺨﺼـﻮﺹ ﺩﺭ ﻛﺸـﻮﺭ ﻣﺎ، ﺟـﺮﺍﺣﺎﻥ ﺑﻪ ﻃﻮﺭ ﺭﻭﺯﻣـﺮﻩ ﺑﺎ ﺑﻴﻤـﺎﺭﺍﻥ ﺳﺎﻟﻤﻨـﺪ ﻭ ﻳﺎ ﺑﻴﻤﺎﺭﺍﻧﻲ ﻛﻪ ﺑﻪ ﻋﻠﺖ ﺳﺎﻟﺨـﻮﺭﺩﮔﻲ، ﺑﻴﻤـﺎﺭﻱ ﻫﺎﻱ ﻧﺎﺗﻮﺍﻥ ﻛﻨﻨﺪﻩ ﺩﻳﮕـﺮﻱ ﻧﻴـﺰ ﺩﺍﺭﻧﺪ ﺑﻴﻤـﺎﺭﻱ ﻫﺎﻱ ﻫﻤـﺮﺍﻩ( ﻣـﻮﺍﺟﻪ ﻣﻲ ﺑﺎﺷﻨـﺪ ﻭ ﺍﺯ ﺁﻧﺠﺎﺋﻲ ﻛﻪ ﺑﻪ ﺧﺼـﻮﺹ ﺩﺭ ﻛﺸﻮﺭﻫﺎﻱ ﺻﻨﻌﺘـﻲ ﻭ ﻫﻤﭽﻨﻴﻦ ﺩﺭ ﻛﺸﻮﺭ ﻣﺎ ﺑﻴﻤـﺎﺭﻱ ﻫﺎﻱ ﻗﻠﺒﻲ ﺷﺎﻳﻌﺘـﺮﻳﻦ ﻋﻠـﺖ ﻣـﺮﮒ ﻭ ﻣﻴـﺮ ﺩﺭ ﺑﺰﺭﮔﺴﺎﻻﻥ ﺍﺳـﺖ، ﺍﻧﺘﻈﺎﺭ ﻣﻲ ﺭﻭﺩ ﻛﻪ ﺑﻴﻤـﺎﺭﺍﻧﻲ ﻛـﻪ ﺑـﺮﺍﻱ ﻋﻤـﻞ ﺟـ ـﺮﺍﺣﻲ ﻣـ ـﺮﺍﺟﻌﻪ ﻣـﻲ ﻧﻤـ ـﺎﻳﻨﺪ ﻧﻴـ ـﺰ ﺩﭼـ ـﺎﺭ ﻧﺎﺭﺍﺣﺘﻲ ﭘﻨﻬـﺎﻥ ﻭ ﻳﺎ ﺁﺷﻜﺎﺭ ﻗﻠﺒﻲ ﺑﺎﺷﻨـﺪ. ﺍﺯ ﺍﻳﻦ ﺟﻬﺖ ﺍﺳـﺖ ﻛﻪ ﻛﺸـﻒ ﻭ ﺩﺭﻣـﺎﻥ ﺍﻳﻨﮕـﻮﻧﻪ ﺑﻴﻤـﺎﺭﺍﻥ ﻗﺒـﻞ ﺍﺯ ﻋﻤـﻞ ﺟـﺮﺍﺣﻲ ﺩﺭ ﺍﻭﻟـﻮﻳﺖ ﻧﺨﺴﺖ ﻗـﺮﺍﺭ ﺩﺍﺭﺩ؛ ﻭ ﭘﺲ ﺍﺯ ﺁﻥ ﺑﻴﻤـﺎﺭﺍﻥ ﺭﻳـﻮﻱ، ﺑﻴﻤﺎﺭﺍﻥ ﺩﻳﺎﺑﺘﻴـﻚ ﺑﺨﺼﻮﺹ ﺁﻧﻬـﺎ ﻛﻪ ﺍﻧﺴﻮﻟﻴـﻦ ﻣﺼـﺮﻑ ﻣﻲ ﻛﻨﻨـﺪ، ﺑﻴﻤـﺎﺭﺍﻥ ﻣﺒﺘـﻼ ﺑﻪ ﭘﺮﻓﺸـﺎﺭﻱ ﺧـﻮﻥ، ﺑﻴﻤـﺎﺭﺍﻥ ﻛﻠﻴـﻮﻱ ﻧﻴﺰ ﺑﺎﻳﺴﺘﻲ ﻗﺒﻞ ﺍﺯ ﻋﻤـﻞ ﺟـﺮﺍﺣﻲ ﺩﺭﻣﺎﻥ ﻭ ﻛﻨﺘـﺮﻝ ﺷﻮﻧﺪ؛ ﻫﻤﭽﻨﻴﻦ ﺑﻴﻤـﺎﺭﺍﻥ ﺳﺎﻟﻤﻨـﺪ ﻛﻪ ﮔـﺬﺷﺘﻪ ﺍﺯ ﺳﺎﻟﻤﻨـﺪﻱ ﺑﻪ ﻋﻠﺖ ﺳﺎﺑﻘـﺔ ﺳﺎﻳﺮ ﺑﻴﻤـﺎﺭﻱ ﻫﺎ ﻣـﺪﺗﻲ ﺍﺯ ﺗﻐـﺬﻳﻪ ﻣﻄﻠـﻮﺏ ﻭ ﻣﻨﺎﺳﺒـﻲ ﺑﺮﺧـﻮﺭﺩﺍﺭ ﻧﺒـﻮﺩﻩ ﺍﻧﺪ، ﻧﻤﻲ ﺗﻮﺍﻧﻨﺪ ﻣﺎﻧﻨـﺪ ﺳﺎﻳﺮ ﺑﻴﻤـﺎﺭﺍﻥ ﺩﺭ ﺑﺮﺍﺑﺮ ﺍﺳﺘـﺮﺱ ﻭ ﺳﺎﻳـﺮ ﭘﻴﺎﻣـﺪﻫﺎﻱ ﺟـﺮﺍﺣﻲ ﻣﻘـﺎﻭﻣﺖ ﻛﻨﻨﺪ. ﭘﺲ ﺑﺎﻳﺴﺘﻲ ﻋـﻮﺍﻣﻞ ﺧﻄـﺮ ﺁﻓـﺮﻳﻦ ﻭ ﺧﻄـﺮ ﺳﺎﺯ ﻭ ﺁﻥ ﺩﺳﺘﻪ ﺍﺯ ﺑﻴﻤـﺎﺭﺍﻥ ﻛﻪ ﻋﻤﻞ ﺟﺮﺍﺣﻲ ﺩﺭ ﺁﻧﻬﺎ ﻭﺍﺟﺪ ﺭﻳﺴﻚ ﺑﺎﻻﺗﺮﻱ ﺍﺳﺖ، ﺭﺍ ﺷﻨﺎﺳﺎﻳﻲ ﻛـﺮﺩﻩ ﻭ ﺁﻧﻬﺎ ﺭﺍ ﻗﺒﻞ ﺍﺯ ﻋﻤﻞ ﺟﺮﺍﺣﻲ ﺩﺭ ﺑﻬﺘـﺮﻳﻦ ﺷﺮﺍﻳﻂ ﻭ ﻭﺿﻌﻴـﺖ ﻣﻤﻜﻦ ﺟﻬﺖ ﻋﻤﻞ ﺟـﺮﺍﺣﻲ ﻗـﺮﺍﺭ ﺩﺍﺩ. ﻋـﺪﻩ ﺍﻱ ﺍﺯ ﺑﻴﻤﺎﺭﺍﻥ ﺑﻪ ﻋﻠﺖ ﺑﻴﻤـﺎﺭﻱ ﻫﺎﻱ ﻫﻤـﺮﺍﻩ، ﺩﺍﺭﻭﻫﺎﻳﻲ ﻣﺼﺮﻑ ﻣﻲ ﻛﻨﻨﺪ ﻛﻪ ﻧﺎﭼـﺎﺭ ﺑﻌﻀﻲ ﺍﺯ ﺁﻧﻬﺎ ﺭﺍ ﺑﺎﻳﺴﺘـﻲ ﻗﺒﻞ ﺍﺯ ﻋﻤﻞ ﺟـﺮﺍﺣﻲ ﻗﻄﻊ ﻛﺮﺩ ﻭ ﻳﺎ ﺑﺎ ﺩﺍﺭﻭﻱ ﺩﻳﮕﺮﻱ ﺟﺎﻧﺸﻴﻦ ﻧﻤـﻮﺩ ﻭ ﻳﺎ ﺍﻳﻨﻜﻪ ﺑﻪ ﻃﻮﺭ ﻛﻠـﻲ ﺗﺤﺖ ﺩﺭﻣﺎﻥ ﻗـﺮﺍﺭ ﺩﺍﺩ ﻭ ﺑﻪ ﻋﺒـﺎﺭﺕ ﺩﻳﮕـﺮ ﺑﺮﺍﻱ ﺁﻧﻬﺎ ﻗﺒﻞ ﺍﺯ ﻋﻤﻞ، ﺩﺍﺭﻭ ﺷﺮﻭﻉ ﻛـﺮﺩ. ﺑﺮﺍﻱ ﺍﻳﻦ ﻛﺎﺭ ﻋـﻮﺍﻣﻞ ﺧﻄـ ـﺮ ﺳـﺎﺯ ﻗﻠﺒـﻲ، ﺭﻳـﻮﻱ، ﻣﺘﺎﺑﻮﻟﻴـ ـﻚ ﻭ ﻧﻴـ ـﺰ ﻭﺿﻌﻴـ ـﺖ ﺳـﻼﻣﺖ ﻛﻠـﻲ ﺑﻴﻤـ ـﺎﺭ ﻭ ﺷـ ﺮﺍﻳﻂ ﻓﻴﺰﻳﻮﻟـﻮﮊﻳﻜﻲ ﺍﻭ ﺭﺍ ﺑﺎﻳﺴﺘﻲ ﻗﺒﻞ ﺍﺯ ﻋﻤﻞ ﺟﺮﺍﺣﻲ ﻣـﻮﺭﺩ ﺑﺮﺭﺳﻲ ﻭ ﺩﻗـﺖ ﻗـﺮﺍﺭ ﺩﺍﺩ ﻭ ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ ﺁﻧﻬﺎ ﺍﮔـﺮ ﺍﺣﺘﻴﺎﺝ ﺑﻪ ﺩﺭﻣـﺎﻥ ﻭ ﺑﻬﺒـﻮﺩ ﺑﺨﺸﻴﺪﻥ ﻭ ﺑﺮﻃـﺮﻑ ﻛﺮﺩﻥ ﺑﻌﻀﻲ ﺍﺯ ﻋـﻮﺍﻣﻞ ﺧﻄـﺮﺳﺎﺯ ﺍﺳﺖ ﺍﻗـﺪﺍﻡ ﻧﻤـﻮﺩ. ﺩﺭﺳﺖ ﺍﺳﺖ ﻛﻪ ﺍﻳﻦ ﻛﺎﺭ ﺍﻏﻠـﺐ ﻭ ﻋﻤـﺪﺗﺎﹰ ﺩﺭ ﺣﻴـﻄﺔ ﻣﺴﺌﻮﻟﻴـﺖ ﭘﺰﺷﻜﺎﻥ ﻣﺸﺎﻭﺭ ﺍﺳﺖ ﻭﻟﻲ ﺟـﺮﺍﺡ ﻫـﻢ ﺑﺎﻳﺪ ﺍﺯ ﺁﻧﻬﺎ ﺍﻃـﻼﻉ ﺩﺍﺷﺘﻪ ﺑﺎﺷﺪ ﺗﺎ ﺍﻭﻻﹰ ﺑﺘﻮﺍﻧﺪ ﺍﺯ ﻣﺸﺎﻭﺭﻳﻦ ﻻﺯﻡ ﺍﺳﺘﻔـﺎﺩﻩ ﻛـﺮﺩﻩ ﻭ ﺛﺎﻧﻴﺎﹰ ﺑﺘـﻮﺍﻧﺪ ﺳﻴﺮ ﺩﺭﻣﺎﻥ ﺑﻴﻤـﺎﺭ ﻭ ﻧﺘﻴﺠﻪ ﻣﻮﺭﺩ ﺍﻧﺘﻈـﺎﺭ ﺍﺯ ﺩﺭﻣﺎﻥ ﺭﺍ ﺩﻧﺒﺎﻝ ﻧﻤـﺎﻳﺪ ﻭ ﺩﺭ ﻧﻬﺎﻳﺖ ﺁﻧﻜﻪ ﻋﻤـﺪﺗﺎﹰ ﺟـﺮﺍﺡ ﻣﺴﺌـﻮﻝ ﺗﻤـﺎﻡ ﻛﺎﺭﻫﺎﻱ ﺩﺭﻣـﺎﻧﻲ ﺍﺳﺖ ﻛﻪ ﺑﺮﺍﻱ ﺑﻴﻤـﺎﺭﺵ ﺍﻧﺠـﺎﻡ ﻣﻲ ﺷﻮﺩ.

There has been a worldwide increase of longevity in the recent decades. Statistically ischemic heart disease and other heart problems has also increased dramatically, and is said to be number one killer in industrial and semi-industrial countries. So any patient that undergoes surgery may have an active or silent coronary artery disease; this should be diagnosed and treated or guarded against preoperatively, the second distressing problem that may need treatment is pulmonary problems as the second more common postoperative complication. Other diseases that needs to be recognized and treated preoperatively are diabetes mellitus; hypertension and renal disease. The increasing number of geriatric patients, besides their age; may have other comorbidities that need special attention and treatment, so is their nutritional status. Nutritional problem and cachexia makes them more susceptible to the stress and hypermetabolic state that surgery can produce. So the surgeon should be aware of all the risks and complications that the patient can face with them. Some of the patients are on different medications that some should be continued, and some either stopped or replaced with other medications. It is quite rational that all surgeons have a good view of their patients' problems; so they could be treated on time or be referred to other especialities for consultation and treatment. It is true that most of the patients comorbidities are in the field of other especialities; but the surgeon is on a whole, responsible for what happens to his patient and what would be the outcome of surgery.