Taking care of patient in PACU after Maxillary surgery

1. Oral and Maxillofacial Surgery
By Alina McCallum RN, CPAN, CL II

2. Why maxillofacial surgery?
 When orthodontic treatment alone can not correct the problem
 To improve facial symmetry and esthetics
 To align teeth correctly
 To enhance jaw function (chewing and swallowing)
 To improve speech and breathing
 To enhance long term jaw stability
 To decrease jaw pain (TMJ disorders)
 Facial trauma reconstruction
 Neoplasm removal
 Avulsed (knocked out) teeth
 Cosmetic

3. Orthognathic procedure
(from Greek: orthos-straight, gnathos-jaws)
 Combination of orthodontic treatment and surgical procedure
to correct abnormalities of the maxilla, mandible or both
involving all three planes of space
 Once growth has ceased, surgery is the only option to correct
severe jaw discrepancy

4. Jaw ( also referred to as mid and lower face)
Maxilla
• Biggest bone of the middle
part of the maxillofacial
It consists of a central body
that is hollowed by
maxillary sinus and four
processes
Mandible
• Only movable bone of the skull
Strong horse shoe-shaped
body that continues up and
backward on either side of the
skull

5. Maxillary Osteotomies
Mid Face Maxillary
Osteotomies
Segmental
Single/multiple
Teeth
Anterior/Posterior
Segmental
Horseshoe
Total
LeFort I
Surgically Assisted
Maxillary
Expansion (SAME)
LeFort II LeFort III

6. Lower Jaw Osteotomies
Mandible
Bilateral Sagittal
Split Osteotomy
(BSSO)
TransOral Vertical
Ramus Osteotomy
(TOVRO)
Chin
(Genioplasty)
Sliding
Reconstruction
with grafts

7. Total Maxillary Osteotomies
•LeFort I. Also known as a horizontal maxillary
osteotomy, the fracture or surgical cut occurs at the
base of the upper jaw above the apices of the teeth
roots
•LeFort II. Also known as a pyramidal osteotomy
because the surgical cuts begin in the midfacial bones
(especially the upper jaw) and meet above the nasal
bones to form a triangular section of bone that is
detached from the skull
•LeFort III. Also known as a craniofacial disjunction or
transverse osteotomy, the facial bones are separated
from the cranial base

8. Bilateral Saggital Split Osteotomy (BSSO)
For Deficiency
Mandibular Osteotomies
For Excess

9. For correction of mandibular deficiency
Usually done at the time of maxillary/mandibular
procedure
Sliding osteotomy (all directions)
Augmentation with implants
Genioplasty

10.  It is not normally necessary to wire the patient’s teeth. Titanium plates,
plastic splints, acrylic and elastic bands are used for fixation of the jaws
 Elastics are most common and important to
 control the patient’s bite during the healing process
 compensate for postoperative swelling that tends to shift the
patient’s bite
 help give some small movement to the teeth
 seat the TMJs
Jaw Immobilization

11.  Maintain close communication with anesthesiology PRIOR
patient’s arrival to PACU regarding the plan of care
 Extubation in OR vs in PACU
 Estimated time the patient will remain intubated
 Sedation
 PONV prevention
 Pain management
 Special considerations (difficult airway, pre anxiety, PONV)
 Expected outcomes
Plan of care in PACU

12.  Have T-piece adapter and oxygen
delivery system ready before
patient arrives to PACU
 Secure nasal ET tube securement
to mid forehead
 Nasal and oral suctioning PRN
 Observe VS (respiratory rate and pattern, SPO2)
 Sedation as per anesthesiologist
 Soft wrist restraints only if danger of self extubation
and/or injury exists
 Be prepared for sudden emergence, have another RN
readily available to temporary assist with care
Care of the Intubated patient

13.  Anesthesiologist must be present during extubation
 Assess patient’s readiness
 sustained spontaneous respirations
 adequate oxygenation
 stable VS
 return of protective reflexes
 able to lift the head
 firm hand grasp and eye opening on command
 audible air leak when ET tube balloon deflated
HAVE INTUBATION TRAY READY AND BE PREPARED TO
REINTUBATE!
Extubation

14.  Airway obstruction
 Bleeding
 Vomiting
 Swelling
 Pain
 Numbness
Immediate post op complications

15.  Mostly due to soft tissue swelling and hematoma
 Common in patients with Hx asthma
Nursing interventions
 observe VS/ SPO2
 monitor respiratory effort and rate
 encourage deep breathing and coughing
 suction PRN
 inhalers PRN
 systemic steroids
 reintubate if needed
Airway obstruction

16.  Minor to moderate oozing from incisions inside the mouth is
expected
 Some trickling of blood from the nose is common in upper jaw
procedures
 Sudden and/or prolonged gush of bright red blood needs to be
addressed immediately and MD notified
Nursing interventions
 Observe for frequent swallowing and c/o nausea
 Assist with intraoral suctioning. Swallowing of the blood may
contribute to nausea and vomiting
 VS monitoring (hypotension/tachycardia)
 Wire cutters within the reach (if wires used)
 Saline nasal sprays and decongestants as ordered
 HOB elevated
Bleeding

17.  High incidence in maxillary procedures
 Prevention of vomiting is paramount
 Limited jaw mobility due to presence of wires, elastics, splints
and bands increases risk of aspiration
Nursing interventions
 Scheduled and PRN antiemetics
 Aromatherapy
 Limit use of narcotics if possible
 HOB elevated
 Frequent suctioning of bloody secretions
 Wire cutters at bedside
 NPO
Vomiting

18.  Mostly from fluids administered during surgery
 Moderate to severe swelling is expected
Nursing interventions
 HOB elevated
 Ice pack around the face
 Local steroids
 Hydrocortisone ointment to lips
 Systemic steroids
 Depomedrol IM on arrival to PACU
 Dexamethazone routine schedule
Swelling

19.  Pain initially not severe due to intraoperative use of local
anesthetics
 Numbness, burning, itching and tingling to face and lips is
expected and it may persist for weeks
Nursing interventions
 Opioids
 NSAIDS
 Ice packs
 Positioning
 HOB elevated
Pain and Numbness

21. Huang CS, Hsu SS, Chen YR. Systematic review of the surgery-first approach in orthognathic
surgery. Biomed J. 2014; 37(4):184-190.
American Association of Oral and Maxillofacial Surgeons. Parameters of Care: Clinical Practice
Guidelines for Oral and Maxillofacial Surgery (2012).
Operative Time, Airway Management, Need for Blood Transfusions, and In-Hospital Stay for
Bimaxillary, Intranasal, and Osseous Genioplasty Surgery: Current Clinical Practices. Journal of
Oral & Maxillofacial Surgery (02782391) (J ORAL MAXILLOFAC SURG), Mar2016; 74(3): 590-600.
(11p)
Carolinas Center for Oral and Facial Surgery website: mycenters.com
Oral and Maxillofacial Surgery website: drmarkpetryna.com
Robinson, R. C., & Holm, R. L. (2010). Orthognathic Surgery for Patients with Maxillofacial
Deformities. Association of PeriOperative Registered Nurses, 92(1), 28-52.
http://dx.doi.org/10.1016/j.aorn.2009.12.030
References