The document discusses postoperative care and complications. It covers two phases of postoperative care (Phase I requiring intensive care and Phase II progressive care), assessing the patient's vitals and airway, and complications including hemorrhage, infection, fever, fluid imbalance, and respiratory issues like atelectasis and pulmonary embolism. Prevention and treatment focus on monitoring, antibiotics, oxygen therapy, IV fluids, and early mobilization.

3. 28/07/2015 monday

4. Ends with the follow up visit
by the patient
Prepare to remove the
surgical drape of patient
Begins from the time last
suture placed
Oral and maxillofacial surg.Clin N Am 18-2006 49-58

5. Successful , faster recovery .
Post operative mortality
rate.
.The length of hospital stay.
. Reduce hospital and patient
cost
. Quality care service.

7. • 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.

8. • The first postoperative assessment should
determine:
• intraoperative history and
postoperative instructions
• respiratory status
• mental status.

9. Two phases-
 Phase I
 Phase II

10.  Is immediate recovery phase
 Requires intensive care to detect early
signs of complication.
 Receive a complete patient record from
the operating room

11.  Requiring less observation and less
nursing care than Phase I
 This phase is also known as Step down or
progressive care unit.

12. Assessing the patient
 Monitor vitals-pulse
volume and regularity,
depth and nature of
respiration.
 Assessment of patient’s O2
saturation.

15.  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.

16. 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.

17.  Haemorrhage
It 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.

18. • 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 .

19.  Use warmer(Bair
Hugger) blankets
 Use warm lights

20.  Administer opioid
analgesia as per
Doctor’s order.
 Epidural analgesia.
 NSAIDS.
 Psychological support to
relieve fear+To give
support.

21. These are common
problem in post
operative period.
Medication can be
administered as per
doctor’s order.
Example:
Inj Metaclopramide
Inj Ondansetron
( Emeset )

22. • 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%

23. • The cardiovascular system is stable with
no unexplained cardiac irregularity or
persistent bleeding.
• The patient’s pulse and blood pressure
should approximate to normal

24. • 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

25. 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)

26. • 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.

27. • 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.

29. • POSTOPERATIVE FEVER,
• ATELECTASIS, WOUND
INFECTION,
• EMBOLISM
• DEEP VEIN THROMBOSIS (DVT).
GENERAL
• IMMEDIATE
• EARLY POST OPERATIVE
• LATE
SPECIFIC
TO TYPE OF
SURGERY

31. • IMMEDIATE
LOW 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.

32. POSTOPERATIVE WOUND INFECTION
ACUTE URINARY RETENTION
SECONDARY HAEMORRHAGE: OFTEN AS A RESULT OF
INFECTION
NAUSEA AND VOMITING:
ANALGESIA OR ANAESTHETIC-RELATED; PARALYTIC ILEUS.

33. Recurrence of lesion -
eg, malignancy.
Persistent sinus.

34. • 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

35. • Sepsis (Eg Infection Of Chest, Urinary Tract,
Wound, Intravenous Cannula Site, Or Intra-
abdominal Collection)
• Sedative Drugs
• Hypoxaemia
• Hypercarbia
• Hypoglycaemia

36. • Myocardial Infarction
• Urinary Retention
• Alcohol/Drug Withdrawal
• Biochemical Abnormality (Eg Urea, Sodium,
Potassium, Calcium, Thyroid Function, Liver
Function).

37. • 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

38. 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
SSI
UTI
.INFECTED
PROSTHSIS OR
GRAFT
.SABE
INFLAMMATION SURGICAL
TRAUMA,TRANSFUSIO
N REACTION
.ATELECTASIS
.GRAFT REJECTION
GRAFT REJECTION
DRUGS ANESTHETIC AGENT DRUG REACTION
MALGNANT
HYPERTHERMIA
DRUG FEVER DRUG OR ALCOHOL
WITHDRAWAL
VASCULAR MYOCARDIAL
INFARCTION
FAT EMBOLISM
MYOCARDIAL
INFARCTION
DVT DVT
.PULMONARY
EMBOLISM
.CAVERNOUS
VENOUS
THROMBOSIS
OTHERS HEAT INSULATION HYPERTHYROIDISM HYPO
ADRENLISM,DEHYDRA
TION
DEHYDRATION

39. • >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

40. • Common physical cooling methods
• Intra peritonial lavage of cool fluid,gastric
lavages or enemas with iced water
• NSAIDs include aspirin
• Ibuprofen and
paracetamol(acetaminophen)

41. • 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

42. • 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.

43. 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

44. RX
IDENTIFICATION RESUSCITAION IDENTIFYING THE SOURCE
ANTIBIOTICS
end-organ dysfunction and/or failure
generalised inflammatory reaction in organs
remote from the initial insult
Systemic inflammatory response to infection

45. • 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.

46. • Fever/Hypothermia
• Unexplained tachycardia/ Tachypnoea
• Signs of peripheral vasodilation
• Hypotension/shock
• Changes in mental state
• Leucocytosis/neutropenia
• Alteration in renal or liver function

47. • 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.

48. • 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 .

49. • FACTORS WHICH MAY AFFECT HEALING RATE
ARE:
• Poor blood supply.
• Excess suture tension.
• Long-term steroids.
• Immunosuppressive therapy.
• Radiotherapy.
• Malnutrition and vitamin deficiency.

50. 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).

51. • 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

52. • 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 .

53. • 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 .

54. • 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.

55. • 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.

56. • 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.

57. • 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.

58. • 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

59. • 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.

60. • 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

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

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

63. • 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.

64. • 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.

65. • 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.

66. • 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

67. • 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.

68. • 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

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

70. • 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