GOOD MORNING

POST OPERATIVE CARE IN ORAL AND

MAXILLOFACIAL SURGERY

28/07/2015 monday

Dr.Abhishek PTDpt. Oral and Maxillo-facial Surgery

INTRODUCTION

Oral and maxillofacial surg.Clin N Am 18-2006 49-58

Successful , faster recovery .

Post operative mortality rate.

.The length of hospital stay.

. Reduce hospital and patient cost

. Quality care service.

PURPOSES

THE FIRST POST OPERATIVE

ASSESSMENT WHEN AND WHO??

• Immediately after surgery on return to the ward.

• It provides a baseline against which the patient’s condition may subsequently be assessed and identifies any problems that may have occurred on transfer from the OT.

• The first postoperative assessment should determine:

• intraoperative history and postoperative instructions• respiratory status• mental status.

PHASES OF POST OP UNIT

Two phases- Phase I Phase II

Phase I

Is immediate recovery phase Requires intensive care to detect

early signs of complication. Receive a complete patient record

from the operating room

Phase II Requiring less observation and less

nursing care than Phase I This phase is also known as Step

down or progressive care unit.

PATIENT MANAGEMENT IN POST OP UNIT

Assessing the patient

Monitor vitals-pulse volume and regularity, depth and nature of respiration.

Assessment of patient’s O2 saturation.

KEEP MONITORING VITALS

MAINTAIN INTAKE AND OUTPUT

Protect airway

By proper positioning of patient’s head.

By clearing airway. Oxygen therapy. Pharyngeal obstruction

can occur when the patient lies on the back as there are chances for tongue to fall back.

Maintaining IV Stability

Hypovolemic shock: can be avoided by timely administration of IV Fluids, blood and blood products and medication.

Replacement of fluids.[colloids and crystalloids]

Keep the patient warm. Monitor intake and output

balance. Monitor the vitals continuously

with the patient condition.

ASSESSMENT OF THE SURGICAL SITE

HaemorrhageIt is a serious complication of surgery that resulting death.

It can occur in immediate post operatively or upto several days after surgery.

If left untreated,cardiac output decreases and blood pressure and Hb level will fall rapidly.

• The surgical site+incision should always be inspected.

• If bleeding,pressure dressing are placed.

• If the bleeding is concealed,the patient is taken for emergency exploration .

KEEP THE PATIENT WARM

Use warmer(Bair Hugger) blankets

Use warm lights

Relieving pain +Anxiety Administer opioid

analgesia as per Doctor’s order.

Epidural analgesia. NSAIDS. Psychological support

to relieve fear+To give support.

Controlling Nausea+VomittingThese are common

problem in post operative period.

Medication can be administered as per doctor’s order.

Example: Inj Metaclopramide Inj Ondansetron ( Emeset )

DISCHARGE FROM POSTANAESTHETIC RECOVERY

• The following criteria must be fulfilled• The patient is fully conscious,• Responding to voice or light touch, • Able to maintain a clear airway• Respiration and oxygen saturation

are satisfactory (10-20 breaths per minute and SpO2 > 92%

• The cardiovascular system is stable with no unexplained cardiac irregularity or persistent bleeding.

• The patient’s pulse and blood pressure should approximate to normal

• pain and emesis should be controlled and suitable analgesic and anti-emetic regimens should be prescribed

• temperature should be within acceptable limits (>36°C)

• oxygen and fluid therapy should be prescribed when required.

• PULSE and BP ~ normal• Stable CVS with no irregularity

PROPHYLAXIS

SHOULD BE DISCUSSED PREOPERATIVELY

• Adequate pain control• Venous thromboembolism prophylaxis

, antibiotic prophylaxis• Continuation of current medications• Substitution of current medication (eg

diabetic control, steroid therapy)

• Prophylaxis for postoperative nausea and vomiting

• Ability of patients to take drugs by mouth

• Pressure area management.Postoperatively, consider the need for:• physiotherapy• nutrition team consultation• oral hygiene.

Daily Assessment• Surgical patients are usually seen once or twice a day on

the ward round and their status must be documented.

• Clear clinical notes must be kept and an entry made every time a patient is reviewed.

• Each daily assessment is an opportunity to modify the monitoring regimen so as best to provide data for clinical decision making.

GENERAL

•POSTOPERATIVE FEVER, •ATELECTASIS, WOUND INFECTION, •EMBOLISM•DEEP VEIN THROMBOSIS (DVT).

SPECIFIC TO TYPE OF SURGERY

•IMMEDIATE•EARLY POST OPERATIVE•LATE

General postoperative complications

• IMMEDIATELOW URINE

OUTPUT

•Inadequate fluid replacement intra-operatively and postoperatively

PRIMARY HAEMORRHAGE

•Either starting during surgery or following postoperative increase in blood pressure –

BASAL ATELECTASIS

•Minor lung collapse

SHOCK•Blood loss, acute myocardial infarction, pulmonary embolism or septicaemia.

EARLYPOSTOPERATIVE WOUND INFECTION

ACUTE URINARY RETENTION

SECONDARY HAEMORRHAGE: OFTEN AS A RESULT OF INFECTION

NAUSEA AND VOMITING: ANALGESIA OR ANAESTHETIC-RELATED; PARALYTIC ILEUS.

LATE

Recurrence of lesion - eg, malignancy.

Persistent sinus.

• Respiratory– Atelectasis – Pneumonia

(aspiration, hypostatic, infectious)

– Embolism• Cardiovascular

– Hemorrhage-shock– Cardiac arrest– DVT

• Musculoskeletal System– Muscle atrophy– Contractures

• Nervous System– Coma – Paralysis

• GIT – Nausea and

vomiting– Constipation– Ulcer (Cushing’s)

• GUT– Urinary retention – UTI

• Wound – Wound infection– Wound dehiscence– Wound evisceration

• Integumentary – Bed sore

• Psychologic – Depression

Common causes of postoperative confusion

• Sepsis (Eg Infection Of Chest, Urinary Tract, Wound, Intravenous Cannula Site, Or Intra-abdominal Collection)

• Sedative Drugs• Hypoxaemia• Hypercarbia• Hypoglycaemia

• Myocardial Infarction

• Urinary Retention

• Alcohol/Drug Withdrawal

• Biochemical Abnormality (Eg Urea, Sodium, Potassium, Calcium, Thyroid Function, Liver Function).

Postoperative fever• Despite being the most frequently

encountered clinial sign, medical and nursing care staffs are still in dilemma in terms of post operative fever

• Incidence :10- 40%

• ‘fever after maxillofacial surgery’ J.maxillofac. Oral surg.(april-june 2015)Amelia,Ravi sharma ,Manikandan

ETIOLOGY INTRA OPERATIVE

IMMEDIATE (WITHIN 24hr)

ACUTE(24-72 hr) SUBACUUTE (AFTER 1 WEEK)

INFECTION .PREOPERATIVE INFECTION

.CLOSTRIDIUM PERFINGES OR STREPTO A

.SURGICAL SITE

.ASPIRATION .PNEUMONIA.UTI.CATHETER .INFECTION

SSIUTI.INFECTED PROSTHSIS OR GRAFT.SABE

INFLAMMATION SURGICAL TRAUMA,TRANSFUSION REACTION

.ATELECTASIS

.GRAFT REJECTIONGRAFT REJECTION

DRUGS ANESTHETIC AGENT DRUG REACTIONMALGNANT HYPERTHERMIA

DRUG FEVER DRUG OR ALCOHOL WITHDRAWAL

VASCULAR MYOCARDIAL INFARCTION

FAT EMBOLISMMYOCARDIAL INFARCTION

DVT DVT .PULMONARY EMBOLISM.CAVERNOUS VENOUS THROMBOSIS

OTHERS HEAT INSULATION HYPERTHYROIDISM HYPO ADRENLISM,DEHYDRATION

DEHYDRATION

MANAGEMENT• >40 C considered harmful and demand active intervention

50% of patients experienced post operative fever,out of which 18% is due to post operative infection.

• However it is said that 50%of diagnosis could have made solely by clinical examinations.

• Lab investigations for for low risk patients is unnecessary

According to : a prospective observational study of 1032 post surgical patients to determine the incidence and utility of extensive postoperative fever evaluations.23.7% were due to infections. According to Lesperence R, Lehman R,Lesperence Kcronk D, Martin P(2011) ,Early post perative fever and routine fever work up

J Surg research 171:245-250

Fever management.....

• Common physical cooling methods• Intra peritonial lavage of cool

fluid,gastric lavages or enemas with iced water

• NSAIDs include aspirin

• Ibuprofen and paracetamol(acetaminophen)

• FEVER DUE TO INFECTIOUS CAUSE requires modification in antibiotic therapy

• Culture and sensitivity examinations

SURGICAL SITE : Antimicrobial dressing

• Irrigation with povidone iodine or chlorhexidine

fever after maxilofacial surgery : clinical review ;R manikandan, Subhash Pramod j. Maxillofac. Oral surg (april – june 2015)14 (2):154-161

Infection

• Postoperative incidence has lessened with the advent of prophylactic antibiotics

• Most common form - superficial wound infection within the first week,

• presenting as localised pain, redness and slight discharge usually caused by skin staphylococci.

INFECTIOUS COMPLICATIONS

CELLULLITIS •TREATED WITH ANTIBIOTICS.

ABSCESS •RQUIRES SUTURE REMOVAL AND PROBING•SURGICAL RE EXPLORATION FOR DEEPER ABSCESS

WOUND SINUS •A LATE INFECTIOUS COMPLICATION ,• OCCUR AFTER APPARENTLY NORMAL HEALING

sepsis

RXIDENTIFICATION RESUSCITAION IDENTIFYING THE SOURCE

ANTIBIOTICS

Systemic inflammatory response syndrome: SIRS

• The response is defined by the presence of two or more of the following:

• Temperature >38*C or <36*C• Heart rate >90 beats/min• White cell count >12,000 cells/mm3 ,

<4,000 cells/mm3, or >10% immature forms.

Clinical signs of sepsis

• Fever/Hypothermia• Unexplained tachycardia/

Tachypnoea• Signs of peripheral vasodilation• Hypotension/shock• Changes in mental state• Leucocytosis/neutropenia• Alteration in renal or liver function

Investigations• Organ dysfunction reflected by altered

platelet count• Coagulation screen, renal function, liver

function and C-reactive protein.• Urine and blood cultures should be

obtained whenever there is reason to suspect systemic sepsis.

MANAGEMENT• Administration of oxygen• Volume expansion using either colloid or

crystalloid.• Antimicrobial therapy• A course of antimicrobial treatment should

generally be limited to 5-7 days. • Surgical intervention in the form of

debridement or drainage of infected, devitalised tissue should be undertaken as soon as possible following haemodynamic stabilisation .

Disordered wound healing

• FACTORS WHICH MAY AFFECT HEALING RATE ARE:

• Poor blood supply.• Excess suture tension.• Long-term steroids.• Immunosuppressive therapy.• Radiotherapy.• Malnutrition and vitamin deficiency.

Cardiovascular management

BRADYCARDIA• A heart rate below 50 beats per

minute may be normal in a patient who is otherwise well.

• Correcting the slow heart rate with a vagolytic agent (eg intravenous glycopyrronium bromide 0.2-0.4 mg or atropine sulphate 0.3- 0.6 mg).

TACHYCARDIA

• Heart rates over 100 beats per minute may be well tolerated by fit patients

• Sustained tachycardia is particularly dangerous for patients who have documented ischaemic heart disease

MYOCARDIAL ISCHAEMIA

• The single most important predictor of serious cardiac events

• Several studies have demonstrated that beta blockers are effective in reducing perioperative MI .

• Reviews suggest that perioperative blockade reduces the incidence of both ischaemia and MI in patients .

Respiratory management

• Pulmonary complications are an important and common cause of postoperative morbidity and mortality .

• If patients at risk can be recognised, it may be possible to modify some risk factors before elective surgery to reduce the rate of these complications .

Respiratory complications

• Respiratory complications occur after major surgery, particularly after general anaesthesia and can include :

• Atelectasis (alveolar collapse):• This is caused when airways become obstructed,

usually by bronchial secretions. Most cases are mild and may go unnoticed.

• Symptoms are slow recovery from operations, poor colour, mild tachypnoea and tachycardia.

• Prevention is by preoperative and postoperative physiotherapy.

• In severe cases, positive pressure ventilation may be required.

• Pneumonia: requires antibiotics, and physiotherapy.

Acute respiratory distress syndrome:

• Rapid, shallow breathing, severe hypoxaemia with scattered crepitations but no cough, chest pains or haemoptysis, appearing 24-48 hours after surgery.

• It occurs in many conditions where there is direct or systemic insult to the lung – eg:multiple trauma with shock.

• The complication is rare and various methods have been described to predict high-risk patients.

Pulmonary embolism• Classically presents with sudden

dyspnoea and cardiovascular collapse with pleuritic chest pain , pleural rub and haemoptysis.

• However, smaller pulmonary emboli are more common and present with confusion, breathlessness and chest pain.

• Diagnosis is by ventilation/perfusion scanning and/or pulmonary angiography or dynamic CT.

Oxygen therapy

• Oxygen can be delivered by a large number of different devices.

• 100% oxygen can only be supplied by endotracheal intubation and positive pressure ventilation.

• Oxygen should be given to patients with hypoxaemia using a device that is best tolerated to achieve the necessary SpO2.

Fluid, electrolyte and renal management

• BASAL REQUIREMENTS IN THE POSTOPERATIVE PATIENT

• The basal requirements for young adults are approximately 30 ml/kg/day of water, 1.0-1.4 mmol/kg/day of sodium and 0.7-0.9 mmol/kg/day of potassium.

• PRINCIPLES OF FLUID BALANCE• As in any patient, the standard principles of fluid

balance in the postoperative patient are:• to correct any pre-existing deficit

• to supply basal needs• to replace unusual losses (eg from

the pre-existing surgical problem, surgical drains, pyrexia)

• To use the oral route where possible; there is often an unnecessary delay in commencing oral intake after maxillofacial surgery.

HYPOVOLEMIA• Possible causes of volume depletion• Unrecognised or uncorrected

preoperative hypovolaemia (including effects of fasting)

• Inadequate intra- or postoperative replacement

• Third space losses (fluid sequestration in the gut or peritoneal cavity, oedema)

• Drain losses• Fistulae

• Polyuric renal failure • Hyperventilation• Nasogastric aspirate• Haemorrhage• Inappropriate use of diuretics

• The specific consequences are:• anastomotic breakdown• cerebral damage• renal failure• multiple organ failure.

OLIGURIA• Oliguria is defined as urine volume of

less than 0.5 ml/kg/hr for two consecutive hours.

• Oliguria in an alert patient, is unlikely to require intervention unless it persists for four hours or more.

• If oliguria is associated with fluid depletion it should be treated initially with a fluid challenge.

• In all cases of oliguria it is important to exclude obstruction of the urinary tract or urinary catheter.

• Diuretics should not be used to treat oliguria and should be reserved for fluid overload.

ACID/BASE BALANCE• Metabolic acidosis is usually due to

poor tissue perfusion but can also be caused by excessive administration of saline.

• A total venous bicarbonate of less than 20 mmol/L or a base deficit of greater than 4 mmol/L may indicate cause for concern, particularly if the trend is towards progressive acidosis.

Acid-Base Balance• large load of acid produced endogenously as a by-

product of body metabolism• acids are neutralized efficiently by several buffer

systems and subsequently excreted by the lungs and kidneys

• Buffers:– proteins and phosphates: primary role in

maintaining intracellular pH– bicarbonate–carbonic acid system: operates

principally in

Common urinary problems

• Urinary retention: this is a common immediate postoperative complication that can often be dealt with conservatively with adequate analgesia. If this fails, catheterisation may be needed, depending on

• surgical factors, type of anaesthesia, co morbidities and local policies.

• UTI: this is very common, especially in women, and may not present with typical symptoms. Treat with antibiotics and adequate fluid intake.

Postoperative nutrition

• Malnourished patients are at increased risk of postoperative complications and mortality, yet artificial nutritional support can be associated with major complications.

• Oral intake should be commenced as soon as possible after surgery

• Anti-emetics should be used as required in order to promote an early return of oral intake.

• All malnourished cancer patients should be considered for nutritional advice and oral supplements in the postoperative period

• For patients with ongoing postoperative complications enteral nutrition should be used whenever possible, combined with parenteral nutrition where necessary, to meet nutritional needs

Refernces• Scottish Intercollegiate Guidelines Net work 77 Postoperative

management in adults• Oral and Maxillofacial Surgery: LASKIN• Prevention and treatment of surgical site infection, NICE Clinical

Guideline (October 2008)• Textbook of oral and maxillofacial surgery- Neelima Malick• Thompson JS, Baxter BT, Allison JG, et al ; Temporal patterns of

postoperative complications.; Arch Surg. 2003 Jun;138(6):596-602• Pile JC; Evaluating postoperative fever: a focused approach. Cleve

Clin J Med. 2006 Mar;73 Suppl 1:S62-6

• Oral and maxillofacial surg.Clin N Am 18-2006 49-58• ‘fever after maxillofacial surgery’ J.maxillofac. Oral surg.(april-

june 2015)Amelia,Ravi sharma ,Manikandan• fever after maxilofacial surgery : clinical review ;R manikandan,

Subhash Pramod j. Maxillofac. Oral surg (april – june 2015)14 (2):154-161