post-operative complications
TRANSCRIPT
April 8, 2023 1
POST-OPERATIVE COMPLICATIONS
DATO’ DR RUSDI ABD RAHMANDEPARTMENT OF ORAL MAXILLOFACIAL SURGERY
HRPZ II
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POST OPERATIVE CONCERNS1. Fever2. Hemorrhage3. Cardiac complications4. Nausea and vomiting5. Urinary retention6. Wound care7. Pain
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FEVERLow grade fever is a common sequelFever under 38°C is not significantHigher demand evaluation1st 24 hours:
Pulmonary atelectasisAspiration pneumoniaIll defined response to surgery
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ContBetween 24 – 72 hours:
Pulmonary atelectasisBacterial pneumoniaThrombophlebitis
After 72 hours:PneumoniaPulmonary embolismIV catheter infectionInfection of the wound or urinary
tractBlood product transfusionDrugs
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1st W - WoundTissue that has been traumatized and
exposed for more than several hours > contaminated
Surgical debridement and copious lavage is of prime important
48 - 72 hours before arising temperature can be attributed to infection of the surgical site
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IV sitePossible sourceIn place for > 24 hours must be suspectedIV lines should be moved to a new site after
72 hoursSigns and symptoms:
Pain TendernessEdemaErythemaStreaking on the limb
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ContTreatment:
1. Remove IV line2. Elevates the limb3. Apply warm and moist packs4. Antibiotics5. If the result of blood culture is positive – refer
to ID specialist
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Breakdown in aseptic techniqueWound infection become apparent between
postoperative days 3 and 7Look for erythema, tenderness, 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 qidImmunologically compromised patient -
imipenem
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2nd W - WindRespiratory complications cause a quarter of
all postoperative deathMost frequent respiratory complication in
OMFS:Pulmonary atelectasisAspiration pneumoniaPulmonary embolus
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Pulmonary atelectasisImperfect expansion of the lung in a small area of alveoliBase-of-lung segmentsUsually in patient who smokeUsualy begin within 24 – 48 hoursCauses:
Use of cuffed endotracheal tubesDepressed mucosalivary clearance due to the drying effect
of the gasesLong period of preoperative fasting > dehydrationProlonged anesthesiaDepression of respiration and the cough reflex by pain or
postoprative sedatives
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Treatment Symptoms are not severe
Physiotherapy Deep breathing exercises Ambulation
More serious symptoms, including fever and dyspneaChest radiograph for evaluation – to exclude
pneumonia and segmental collapsePneumonia > antibiotic therapySegmental collapse > bronchoscopic
evaluation and referral
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Aspiration pneumoniaInhalation of foreign materialCauses:
Poor throat pack sealUncuff ET tubeDepression of cough reflexDuring sedative therapyIMF
Frequent in right lungFever as early as 3 - 5 days or as late 2 – 3
weeks after surgery
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ContPresentations
Malaise, cough, sputum production, pleuritic pain
TreatmentAppropriate specialistHigh doses of AB, eg Timentin
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Pulmonary embolusBlood clot lodged in the pulmonary artery or one of its
branches.The clot formed peripherally, broke free and become
trapped in the pulmonary vascular circulationPrevention – ambulate earlyUsually, 5 – 10 days precede the the developmentChief cause – Virchow’s triad
1. Damage to the endothelial lining2. Stasis or diminution in the rate of flow3. change in the blood contituents due to a postop
increase in the number and adhesiveness of the platelet
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ContClinical features – fever, chest pain, sudden
dyspnea, tachypnea, hemoptysisConfirmation – ventilation perfusion lung
scan, pulmonary angiography. Noninvasive – US imaging, impendance plethysmography
Treatment 1. Limb elevation2. Systemic anticoagulant3. Oral anticoagulant4. Thrombolytic therapy – to be avoided
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3rd W - WaterCaused by an indwelling catheter or
intermittent catheterizationWomen are at greater risk because of the
short female urethraThe stress of surgery may unmask an
asymptomatic bacteriuria and allow UTI to develop
Symptoms – fever, dysuria, burning pain with urination, cloudy urine
Treatment – urine analysis and culture, antibiotic therapy
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5th W – Wonder drugs and transfusionMany drugs have been implicatedBacterial etiology should be rule-out before
the fever is attributed to medicationHow?
Presence of an eosinophilia, absence of leucocytosis and lack of systemic symptoms may suggest drug’s etiology
Fever secondary to a drug reaction is not accompanied by an increase in the heart rate
Treatment – removed the offending drug
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TransfusionA common source of feverMild febrile reaction – NTRFever with tachycardia, chills, back pain,
dyspnea, micro vascular bleeding > a major transfusion reaction must be suspected
TreatmentStop the transfusionPatients blood should be cross matched againShould hemolysis occur, patient will required
forced diuresis and alkalization of the urine to prevent renal toxicity.
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Nausea and vomitingMore frequent in children than adultWomen > menObeseMotion sicknessThe longer the op, the greater the likelihood that there will
be operative nausea and vomiting Causes
StarvationBlood in the stomachDrugs
Narcotics, metronidazole etcHypotensionHypoxia
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ContNarcotic analgesics is a common cause If this occur, changed to NSAIDS alonePt on narcotics following surgery must be given
antiemetics such as:metoclopramide (Maxolon) 10 mg IM qidProchlorperazine (Stemetil) 12.5 IM tds
Pt who swallowed bld peri and post operatively – give antacids or indigestion remedies
Pt must also be given IV fluids administration to help restore and maintain fluid, electrolyte and sugar balance.
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Pain Subjective phenomenaDifficult to measure objectivelyDependent on the complexities of surgeryDependent on the pt’s individual response to pain (pain
threshold)Essential part of the postoperative careMust must be pain-free postoperativelyPrescribed analgesics generouslySelection based on
Patient toleranceHistory of allergyComplexity of the surgeryCost
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ContTake as required philosophy PRN
Brief periods of reliefMore frequent pain cyclesDecreased analgesic effectivenessOveruse of the medicationAbuse of the medication
More acceptable practiceRegular interval – bd, tds, qidFor a specific period of timeUntil which sufficient symptomatic relief is achived so that it is
no longer requiredAnalgesic taken at regular interval
Reduce the likelihood of intolerable painImprove post-op comfortPromote a more rapid recovery
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NSAIDsMost commonly prescribedFor mild to moderate pain arising from
inflammatory processEg
AspirinParacetamolPonstanVoltaren
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NarcoticsAct on specific receptors in CNS conferring a
central analgesic effectNot confined to pain arising from
inflammatory processMore effective in dampening the pt’s
emotional response to pain rather than eliminating the pain itself
Useful for severe pain