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17 August 2011
POST OPERATIVE CONCERNS
1. 2. 3. 4. 5. 6. 7.
Fever Hemorrhage Cardiac complications Nausea and vomiting Urinary retention Wound care Pain
17 August 2011
FEVER y Low grade fever is a common sequel y Fever under 38°C is not significant y Higher demand evaluation y 1st 24 hours: y Pulmonary atelectasis y Aspiration pneumonia y Ill defined response to surgery 17 August 2011 3 .
Cont y Between 24 72 hours: y Pulmonary atelectasis y Bacterial pneumonia y Thrombophlebitis y After 72 hours: y Pneumonia y Pulmonary embolism y IV catheter infection y Infection of the wound or urinary tract y Blood product transfusion y Drugs 17 August 2011 4 .
2. 5. Wound Wind Water Walking Wonder drugs 17 August 2011 5 .Principal cause of fever 4Ws 1. 3. 4.
72 hours before arising temperature can be attributed to infection of the surgical site 17 August 2011 6 .st 1 W .Wound y Tissue that has been traumatized and exposed for more than several hours > contaminated y Surgical debridement and copious lavage is of prime important y 48 .
IV site y Possible source y In place for > 24 hours must be suspected y IV lines should be moved to a new site after 72 hours y Signs and symptoms: y Pain y Tenderness y Edema y Erythema y Streaking on the limb 17 August 2011 7 .
Remove IV line 2.Cont y Treatment: 1. Antibiotics 5. Apply warm and moist packs 4. Elevates the limb 3. If the result of blood culture is positive refer to ID specialist 17 August 2011 8 .
crepitation and dischrge. Do Gram staining and cultures. antibiotic sensitivity tests and opening of the operative wound Then give penicillin 1 -2 million U IV qid Immunologically compromised patient .imipenem 17 August 2011 9 . tenderness.Breakdown in aseptic technique y Wound infection become apparent between y y y y postoperative days 3 and 7 Look for erythema.
Wind y Respiratory complications cause a quarter of all postoperative death y Most frequent respiratory complication in OMFS: y Pulmonary atelectasis y Aspiration pneumonia y Pulmonary embolus 17 August 2011 10 .nd 2 W .
Pulmonary atelectasis y y y y y Imperfect expansion of the lung in a small area of alveoli Base-of-lung segments Usually in patient who smoke Usualy begin within 24 48 hours Causes: y Use of cuffed endotracheal tubes y Depressed mucosalivary clearance due to the drying effect of the gases y Long period of preoperative fasting > dehydration y Prolonged anesthesia y Depression of respiration and the cough reflex by pain or postoprative sedatives 17 August 2011 11 .
Treatment y Symptoms are not severe y Physiotherapy y y Deep breathing exercises Ambulation y More serious symptoms. including fever and dyspnea y Chest radiograph for evaluation to exclude pneumonia and segmental collapse y Pneumonia > antibiotic therapy y Segmental collapse > bronchoscopic evaluation and referral 17 August 2011 12 .
5 days or as late 2 3 weeks after surgery 17 August 2011 13 .Aspiration pneumonia y Inhalation of foreign material y Causes: y Poor throat pack seal y Uncuff ET tube y Depression of cough reflex y During sedative therapy y IMF y Frequent in right lung y Fever as early as 3 .
sputum production. pleuritic pain y Treatment y Appropriate specialist y High doses of AB. cough.Cont y Presentations y Malaise. eg Timentin 17 August 2011 14 .
y The clot formed peripherally.Pulmonary embolus y Blood clot lodged in the pulmonary artery or one of its branches. 5 10 days precede the the development y Chief cause Virchow s triad 1. broke free and become trapped in the pulmonary vascular circulation y Prevention ambulate early y Usually. change in the blood contituents due to a postop increase in the number and adhesiveness of the platelet 17 August 2011 15 . Damage to the endothelial lining 2. Stasis or diminution in the rate of flow 3.
tachypnea. pulmonary angiography. chest pain. sudden dyspnea.Cont y Clinical features fever. hemoptysis y Confirmation ventilation perfusion lung scan. impendance plethysmography y Treatment Limb elevation 2. Oral anticoagulant 4. Thrombolytic therapy to be avoided 1. Noninvasive US imaging. 17 August 2011 16 . Systemic anticoagulant 3.
burning pain with urination. antibiotic therapy 17 17 August 2011 . cloudy urine Treatment urine analysis and culture.rd 3 W .Water y Caused by an indwelling catheter or intermittent y y y y catheterization Women are at greater risk because of the short female urethra The stress of surgery may unmask an asymptomatic bacteriuria and allow UTI to develop Symptoms fever. dysuria.
Walking y Should remind you that a lower limb can be the source 17 August 2011 18 .th 4 of the fever W .
absence of leucocytosis and lack of systemic symptoms may suggest drug s etiology y Fever secondary to a drug reaction is not accompanied by an increase in the heart rate y Treatment removed the offending drug 17 August 2011 19 .th 5 W Wonder drugs and transfusion y Many drugs have been implicated y Bacterial etiology should be rule-out before the fever is attributed to medication y How? y Presence of an eosinophilia.
patient will required forced diuresis and alkalization of the urine to prevent renal toxicity. 17 August 2011 20 . dyspnea.Transfusion y A common source of fever y Mild febrile reaction NTR y Fever with tachycardia. micro vascular bleeding > a major transfusion reaction must be suspected y Treatment y Stop the transfusion y Patients blood should be cross matched again y Should hemolysis occur. back pain. chills.
Nausea and vomiting More frequent in children than adult Women > men Obese Motion sickness The longer the op. the greater the likelihood that there will be operative nausea and vomiting y Causes y y y y y y y y y y Starvation Blood in the stomach Drugs y Narcotics. metronidazole etc Hypotension Hypoxia 21 17 August 2011 .
17 August 2011 22 . electrolyte and sugar balance.Cont y Narcotic analgesics is a common cause y If this occur.5 IM tds y Pt who swallowed bld peri and post operatively give antacids or indigestion remedies y Pt must also be given IV fluids administration to help restore and maintain fluid. changed to NSAIDS alone y Pt on narcotics following surgery must be given antiemetics such as: y metoclopramide (Maxolon) 10 mg IM qid y Prochlorperazine (Stemetil) 12.
Pain y y y y y y y y Subjective phenomena Difficult to measure objectively Dependent on the complexities of surgery Dependent on the pt s individual response to pain (pain threshold) Essential part of the postoperative care Must must be pain-free postoperatively Prescribed analgesics generously Selection based on y y y y Patient tolerance History of allergy Complexity of the surgery Cost 23 17 August 2011 .
Cont y Take as required philosophy PRN y Brief periods of relief y More frequent pain cycles y Decreased analgesic effectiveness y Overuse of the medication y Abuse of the medication y More acceptable practice y Regular interval bd. qid y For a specific period of time y Until which sufficient symptomatic relief is achived so that it is no longer required y Analgesic taken at regular interval y Reduce the likelihood of intolerable pain y Improve post-op comfort y Promote a more rapid recovery 17 August 2011 24 . tds.
NSAIDs y Most commonly prescribed y For mild to moderate pain arising from inflammatory process y Eg y Aspirin y Paracetamol y Ponstan y Voltaren 17 August 2011 25 .
Narcotics y Act on specific receptors in CNS conferring a central analgesic effect y Not confined to pain arising from inflammatory process y More effective in dampening the pt s emotional response to pain rather than eliminating the pain itself y Useful for severe pain 17 August 2011 26 .
Compound analgesic y Aspirin + Codeine y Paracetamol + codeine y Paracetamol + hydrocodone 17 August 2011 27 .
17 August 2011 28 .Intraoperative analgesics y Administration of long-acting local anaesthetic drug eg marcain.