Postoperative cancer care

© Ramaiah University of Applied Sciences
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Faculty of Dental Sciences
Post operative cancer care
Dr Zeeshan Arif

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CONTENTS
• Introduction
• Ventilation and oxygenation
• Recovery from GA
• Pain management
• Monitoring
• Respiratory care
• Post op HB
• Safe allowable blood loss
• Wound care
• Flap care
• Fluid balance
• Maintainace of mouth hygiene
• Mobilization
• Drains and catheders
• Communication
• Nutrition
• Deep vein thrombosis
• Hospital acquired infection
• References

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Introduction
• Good post-operative management will have started before the
procedure with appropriate counselling and preparation
• This preparation will have included an assessment of fitness for the
procedure and identification and management of any risk factors.
• The patient will have been provided with a clear explanation of the
procedure, the risk-benefits and the likely outcome.
• The patient's expectations match those of the health professional.

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• The postoperative period begins when surgeons place the last
suture and prepare to remove the surgical drapes.
• The first postoperative concern is the removal of the throat pack if
one was placed.
• Before a throat pack is removed, the mouth should be suctioned to
remove debris and blood clots and the surgeon should keep the
suction going until the throat pack has been removed fully.

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• A good throat pack is one that, when
removed, may be bloody or ‘‘dirty’’ at the
oral end but generally clean on the
tracheal end.
• The removal of the throat pack should be
verified by the surgeon, circulating nurse,
and anesthesiologist.
• The surface of the tongue should be
wiped clean, as residual blood on the
tongue may cause nausea and vomiting.

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Ventilation and oxygenation
• Because most oral and maxillofacial surgical procedures potentially
can compromise the airway, special attention must be paid to
maintaining a patent airway.
• It is the responsibility of oral and maxillofacial surgeons and
anesthesiologists to assure that the airway is protected during and
after surgery.
• Assisted ventilation should be done until patients are able to
maintain ventilation without an anesthetist telling them to breathe.
Post operative care of oral and maxillofacial surgery patient
Orrett ogle. Oral and maxillofacial clinics of north America

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• Keeping the bed head elevated assists breathing and the
management of oral secretions by patients.
• If it is necessary to reverse patients for respiratory depression with
either naloxone (Narcan) or flumazenil (Romazicon), patients should
be observed for at least 2 hours.
• Incomplete reversal of muscle relaxants is the most common cause
in the hospital setting (oversedation is the most common cause in
the office).

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• When patients are not warmed during surgery and are cold, the
reversal of muscle relaxants may not be complete, and cold patients
that seem fully reversed can become reparalyzed as they warm up.
• The peripheral vasoconstriction traps the muscle relaxant in the
tissues, and as patients become warm and the vessels redilate, the
muscle relaxant returns into the circulation and becomes active.
• Patients should be reversed adequately and kept warm

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• Hypoxia is the major concern in the early postoperative period and
its incidence is high.
• Anesthesia depresses respiration and produces ventilation-perfusion
(V/Q) mismatch and pain and shivering that increase the demand for
oxygen.
• After general anesthesia, there always is some degree of alveolar
collapse resulting from a decrease in the functional residual capacity,
which may take days or weeks to return to baseline.

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Recovery from general anaesthesia
• Recovery is a gradual process, dependent on the continued
redistribution of the anaesthetic drug in the body together with
elimination or metabolism.
• The process is timed to result in emergence from anaesthesia as
close as possible to the completion of the surgery.
• A considerable residue of drug may remain, especially in skeletal
muscle, so that secondary peaks can occur in the plasma
concentration following rewarming and restoration of muscle blood
flow.

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• The slow release of the drug from muscle and fat prevents full
recovery of cognitive function for many hours and will potentiate
the effects of any additional sedative drugs.

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Pain management
• The World Health Organization (WHO) recommended a simple and
well-validated stepped regimen for the treatment of pain according
to intensity – known as the WHO ladder.
• The five essential concepts in the WHO approach to drug therapy of
cancer pain are:
• by the mouth
• by the clock
• by the ladder
• for the individual
• with attention to detail.

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• Acetaminophen, aspirin, or other nonsteroidal anti-inflammatory
drugs (NSAIDs) (e.g., naproxen, diclofenac, or indometacin)
• When pain persists or increases, an opioid such as codeine or
hydrocodone should be added (not substituted) to the NSAID.
• Persistent pain, should be treated by increasing opioid potency
(mainly morphine, methadone, or fentanyl).
• When patients cannot take medications orally, the other less
invasive routes (rectal or transdermal) should be tried; parenteral
routes, such as subcutaneous or intravenous, should only be used
when simpler methods are unavailable or ineffective

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Therapeutic approach Technique
Non-invasive pharmacologic
therapy
Oral, rectal, transdermal, subcutaneous, or intravenous
administration of NSAIDs, opioids and adjuvant drugs
Invasive interventions Peripheral nerve blocks
– Maxillary nerve
– Mandibular nerve
– Glossopharyngeal nerve
Ganglion blocks
– Sphenopalatine ganglion
– Trigeminal ganglion
– Stellate ganglion
Central neuraxial techniques
– Intraventricular opiates
– Intrathecal pump

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Intervention Advantages Disadvantages
Oral NSAIDs – Useful for mild to moderate pains
– Widely available, some over the counter
– May be combined with opioids
– Can be administered by patient or carer
– Ceiling effect to analgesia
– Side effects, especially gastritis and
renal toxicity
– May increase risk of bleeding
Oral opioids – Effective for both localised and generalised
pain
– Sedative and anxiolytic properties useful in
some acute treatment settings
– Can be administered by patient or carer
– Long acting, controlled-release forms
available
– Side effects may limit analgesic
effectiveness
– Prescription of these substances is
regulated
– Stigma associated with use fears
Transdermal opioids
(fentanyl)
Long duration of action (48–72 h) Difficult to modify dosage rapidly
Relatively slow onset of action
Subcutaneous
infusion
– Can provide rapid pain relief
– Morphine and its derivates are the preferred
drugs
– Only a limited volume can be
administered
– Induration and irritation at infusion
site
Intravenous infusion – Can provide rapid pain relief
– Almost all opioids can be given by this route
– Infection and obstruction of
intravenous lines are not uncommon
Epidural, intrathecal,
and intraventricular
routes
– Indicated for pain that does not respond to
less invasive measures
– Local anaesthetics may be added to spinal
opioids
– Tolerance may occur
– Infection at catheter site can produce
meningitis and/or epidural abscess
– Pruritus and urinary retention are not
uncommon

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Monitoring
• The vital signs (blood pressure, pulse, O2 saturation and respiratory
state) will be measured and recorded regularly.
• If an arterial catheter has been inserted, blood pressure and pulse
readings can be observed on a monitor constantly.
• Measurement of the central venous pressure may be required for
patients with poor cardiorespiratory reserve or where there have
been large volumes of fluid administered or major fluid shifts are
expected.
• The patient chart will also record all fluid that has been given during
and since the operation, together with fluid lost.

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Respiratory care
• Mechanical ventilation may be required in the early
phase of recovery.
• This can vary from prolonged endotracheal intubation,
to intermittent positive pressure ventilation, to
supplemental oxygenation by facemask or nasal
prongs.
• In these instances the patient may require prolonged
monitoring in an intensive care or high dependency
unit with regular assessment of oxygen saturation
(pulse oximetry and arterial blood gas analysis).

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Post op hb
Practice Guideline 2006 American Society of Anesthesiologists
• Hb less than 6.0 g/dL is a strong indication for
transfusion.
• There should be no blood transfusion if Hb is
higher than 10.0.
• For between 6.0 to 10.0 g/dL, it is based upon
the best clinical judgments, such as evidence of
organ ischemia, bleeding, intravascular volume,
and patients’ own risk factors, which can
predispose patients to have low cardiopulmonary
reserve and high O2 consumption

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Safe allowable blood loss
• The average blood volume that a patient may lose and still maintain
hemoglobin at a safe level is about 25% of hemoglobin drop from
baseline.
• This recommended 25% threshold can actually result in numbers
that are higher than most physicians expect.
• For example, a 25% loss of a start hemoglobin 13.0 g/ dL would be
as high as 9.75; a 25% loss of hemoglobin 12.0 g/ dL would be as
high as 9.0

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Wound Care
• Most surgical wounds undergo primary closure in which there is
minimal tissue loss and the wound edges can be satisfactorily
approximated.
• In the initial phases of healing, there is only minimal tensile strength
in the wound as remodelling of the collagen fibres has not occurred.
• As such, additional support in the form of sutures, staples or tapes is
required until full remodelling and epithelialisation occur.

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Recommendations for preventing SSIs in the post-operative
phase
Dressing and cleaning the wound
• Use an aseptic technique for changing or removing dressings
• untouched for up to 48 h after surgery, using sterile saline for wound
cleansing during this period only if necessary
• Use an interactive dressing for surgical wounds that are healing by
secondary healing
• Refer to a tissue viability nurse (or another healthcare professional
with tissue viability expertise) for advice on appropriate dressings
for surgical wounds that are healing by secondary intention

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Antibiotic treatment
• If a SSI is suspected (ie. cellulitis), either de novo or because of
treatment failure, give the patient an antibiotic
• Choose an antibiotic that covers the most likely causative organisms.
• Consider local resistance patterns and the results of microbiological
tests

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Common pathogens associated with types of operation
Type of operation Common pathogens
Abdominal surgery Gram-negative bacilli, anaerobes,
streptococci
Breast surgery S. aureus, coagulase-negative
staphylococci
Cardiothoracic surgery S. aureus, coagulase-negative
staphylococci
Head and neck surgery S. aureus, coagulase-negative
staphylococci
Neurosurgery S. aureus, coagulase-negative
staphylococci
Obstetrics and gynaecological surgery Gram-negative bacilli, enterococci,
anaerobes, group B streptococci
Orthopaedic surgery S. aureus, coagulase-negative
staphylococci
Vascular surgery S. aureus, S. epidermidis, gram-
negative bacilli

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Flap care
• Many free flap protocols include
warming of the patient and room to
promote peripheral vasodilation and
perfusion.
• Pressure on free flaps should always be
minimized, as excessive pressure may
impede arterial inflow and/ or venous
outflow
• Surgical dressings should be examined
and confirmed to be not excessively
tight.

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• For extremity free flaps, the involved limb
should be elevated to help control edema,
which might otherwise accumulate and
cause pressure on the microvasculature of
the flap.
• Finally, activity restrictions, including weight-
bearing status and range of motion, should
be carefully reviewed, as they may impact
pressure or tension on a free flap.

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• Pedicle flaps: Myocutaneous or osteomyocutaneous flaps based on
a feeding vessel to muscle and perforators to the skin paddle (eg,
flaps based on the pectoralis major, latissimus dorsi, or trapezius)
may be used in a one-stage operation to replace skin, and because
they also contain muscle, they have adequate bulk to repair defects
and may be used to import bone

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Free Flap viability
Capillary Refill
• cutaneous blood is expunged from a small area of the free flap, by
temporarily applying digital pressure, and then pressure is released
to observe the return of blood flow into that area.
• Typically, capillary refill is described in terms of time (normal 2–3
seconds), or whether it is “brisk” versus “delayed.”
• Delayed capillary refill indicates an arterial inflow problem.
• In contrast, excessively brisk capillary refill indicates a venous
outflow problem, as flap tissues become engorged with blood due
to continued arterial inflow.

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Color
• color of the flap skin should exhibit a pink color similar to the site from
which the tissue was transferred
• Pale- problem with the arterial anastomosis resulting in decreased blood
flow into the flap.
• purplish discoloration-this may indicate a problem with the venous
anastomosis, with accumulation of venous blood

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Temperature
• A free flap that is perfusing normally should exhibit a temperature
that is comparable to adjacent nonflap areas of the patient.
• Free flap temperature can be assessed using either an actual
measurement or physical examination, although the latter is
subjective.
• A difference of greater than 1 ° C–3 ° C (1.8 ° F–5.4 ° F) in
temperature between a flap and adjacent nonflap skin may be
indicative of a vascular problem ( Chen et al., 2007 ).

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Turgor
• The balance between vascular inflow and outflow determines tissue
turgor.
• Normally, a free flap should exhibit turgor that is similar to a
patient’s other nonflap tissues.
• If a free flap exhibits diminished turgor, this may herald an arterial
inflow problem.
• Increased prominence of rhytids (wrinkles) on the skin paddle-
arterial inflow problem
• A free flap that is excessively swollen and firm may be experiencing
a venous outflow problem.

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Medical devices
• Acoustic Doppler sonography
• Color duplex ultrasonography
• Flow coupler
• Implantable Doppler
• Laser Doppler flowmetry
• Near-infrared and visible light spectroscopy

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Fluid balance
The three principles of management of fluid balance are:
1. correct any abnormalities
2. provide the daily requirements
3. replace any abnormal and ongoing losses.
• Ideally, any abnormalities will have been identified and corrected
before or during the surgical procedure.
• The normal maintenance fluid requirements will vary depending on
the patient's age, gender, weight and body surface area.

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Basic requirements
• The total body water of an adult comprised 45–60% of the
bodyweight.
• Of the total body water, two-thirds is in the intracellular
compartment and the other one-third is divided between plasma
water (25% of extracellular fluid) and interstitial fluid (75% of
extracellular fluid).

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• The normal daily fluid requirement to maintain a healthy 70-kg adult
is between 2 and 3 L.
• The individual will lose about 1500 mL in the urine and about 500
mL from the skin, lungs and stool.
• Loss from the skin will vary with the ambient temperature.
• The electrolyte composition of intracellular and extracellular fluid
(ECF) varies
• Sodium is the predominant cation in ECF and potassium
predominates in the ICF.
• The normal daily requirements of sodium and potassium are 100-
150 mmol and 60-90 mmol, respectively.

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Replacement
• If an otherwise healthy adult is deprived of the normal daily intake
of fluid and electrolytes, suitable intravenous maintenance must be
provided.
• One relatively simple regimen is 1 L of 0.9% saline and 1–2 L of 5%
dextrose solution.
• Both these solutions are isotonic with respect to plasma.
• The electrolyte solution contains the basic electrolyte requirements
(154 mmol/L of sodium and 154 mmol/L of chloride) and the total
volume can be adjusted with various amounts of dextrose solution.

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• Potassium can be added as required.
• Other solutions (e.g. Ringer's lactate) may contain a more balanced
make-up of electrolytes, but are rarely needed for a patient who is
otherwise well and only requires intravenous fluids for a few days.
• In an adult of average build, maintenance fluids can be restricted to
2 L per day with no potassium supplements until a diuresis has
occurred.

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Maintenance of oral hygiene
1. Normal saline
2. Chlorhexidine is most commonly available as a
0.2 per cent solution.
• However, it has been proven that a 0.12 per cent
solution is just as clinically effective in the
prevention of gingivitis, and reduces the incidence
of side effects.
• Hence it is recommended that a 1:1 dilution with
water be prepared for mouth hygiene use.

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• 3. Povidone iodine-
• It is useful for mucosal infections but does not inhibit plaque
accumulation and should not be used for periods longer than
14 days since a significant amount of iodine is absorbed.
• It is contraindicated as a regular mouth wash in patients with
thyroid disorders or on lithium therapy.
• Side effects include mucosal irritation and hypersensitivity
reactions.

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4. Hydrogen peroxide
• In patients with gross plaque deposits, 3 per cent
hydrogen peroxide solution in a 1:1 dilution with water
may be useful.
• As well as being an effective oxidizing agent against
anaerobic bacteria, it also has a mechanical cleansing
effect due to frothing when in contact with oral debris.
• cleansing established wound dehiscences where debris
accumulation is a concern (due to the effects of gravity).
• Adequate suction is required to remove the froth

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5.Anaesthetic mouth rinses
• These commonly contain either benzocaine cetylpyridinium chloride
or benzydamine hydrochloride, e.g., Difflam which are quaternary
ammonium compound anti-inflammatory agents, in a hydroalcoholic
base.
• Difflam is also available as a chlorhexidine containing solution called
Difflam-C.
• This would be the preferred solution for those patients with mucosal
pain.
• persistent mucositis

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• 6. Listerine contains a combination of phenol-related essential oils,
thymol, eucalyptol, menthol and may also have methylsalicylate in a
hydroalcoholic vehicle, depending on which Listerine product is
being used.
• There have been extensive clinical studies, which demonstrate
reductions in plaque accumulation and gingivitis.
• However, in comparison to chlorhexidine it does not demonstrate
substansivity, is less effective, more expensive and more irritating to
oral tissues.
• Hence, its use in such a patient group is not recommended.

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Suction
• A Yankaur sucker and a flexible suction catheter
is used for removing pooled saliva, blood,
mucous, pus and any other oral secretions.
• This is uncomfortable for the patient and can
predispose to drooling.
• Caution should be used, though, in areas where
free flaps or skin grafts have been placed

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Mobilisation
• Early mobilisation is encouraged.
• The aim of early mobilisation is to encourage good pulmonary
ventilation and to reduce venous stasis.
• For those who cannot mobilise, physiotherapy should be provided to
help with breathing and measures taken to either increase venous
flow (pneumatic calf compression devices) or reduce risks of deep
vein thrombosis (heparin).
• The timing of any planned heparin administration will depend on the
nature of the procedure and the risks of haemorrhage from that
procedure

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Drains and catheters
• Drains may be put down to an operative site or into a wound as it is
being closed to drain collections or potential collections.
• Drains may also be put into the chest cavity to help the lungs re-
expand.
• Drains can act as a point of access for infection, and whilst this may
be of little consequence if the tube has been put in to drain an
abscess cavity, all efforts are made to reduce contamination of any
wound.

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• There is increased use of closed drainage systems and dressings
around drains are changed regularly.
• Any changes to tubes or bags on drains must be carried out using
aseptic techniques.
• Once a drain has served its purpose, it should be removed.
• The longer a drain stays in situ, the greater the risk of infection.
• The contents and volumes discharged through a drain must be
recorded.
• Large volumes, may need the equivalent amount replaced
intravenously.

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Communication
• Most patients will seek some form of reassurance in the immediate
post-operative period.
• How the procedure went and how they are progressing.
• All the tubes, lines and equipment to which they are attached are
quite normal and not an indication of impending disaster.
• Any unexpected finding or complication encountered during the
procedure should be discussed with the patient.
• The timing and detail of this discussion is a matter of fine judgement
and may be best done in the presence of the patient's relatives.

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Nutrition
• Although many factors are involved in assessing overall health status
in patients with cancer, nutrition plays a significant role in
influencing tumor biology, comorbid conditions, and responses to
treatment.
• Clinicians must consider their patients' overall nutritional status
along with any therapeutic interventions being considered, whether
that includes surgery, radiation, chemotherapy, or combinations of
these modalities, to minimize complications and delays in wound
healing in this patient population.

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Nutritional status in patients with cancer
• In most studies assessing weight loss as the primary indicator of
nutritional status in patients with cancer, approximately 40% to 80%
of patients are malnourished, whether this is due to tumor biology,
surgical procedures, radiation or chemotherapy, or psychological
factors.
• Malnourished patients have a greater susceptibility to infectious
complications along with delayed wound healing, which, in
combination with their diseased state, significantly increases
postoperative morbidity and mortality.

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• Malnutrition also increases the metabolic activity of organs such as
the liver, which physiologically borrows substrate from skin and
muscle to maintain vital functions
• Maintaining adequate nutritional balance in cancer patients
undergoing treatment is essential to minimize the risk of
complications such as enteric fistula formation, incisional wound
dehiscence, as well as carotid rupture after head and neck surgery.

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• Physiologic stressors such as infection and injury initiate a series of
metabolic reactions leading to a negative nitrogen balance and
ultimately a decrease in lean body mass.
• Malnutrition has detrimental effects on cellular and humoral
immunity in addition to negatively influencing tissue function and
repair.
• Malnourished cancer patients have less tolerance for therapeutic
interventions than patients in better nutritional states.

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• A minimum requirement of 25 to 30 kJ/kg per day is initially
recommended for critically ill patients.
• Carbohydrates tend to be the primary source of nonprotein calories
during the hypermetabolic state and can comprise 60% to 70% of
the daily nutritional requirements.
• Daily fat requirements account for the additional 25% to 30% of
nonprotein calories in hypermetabolic patients.
• Fat provides not only essential dietary fatty acids but also an energy-
rich substrate to help meet metabolic demands.

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• Amino acids should be provided in adequate amounts to restore the
nitrogen balance and limit muscle breakdown.
• In general, protein requirements in septic or injured patients range
from 1.2 to 2.0 g/kg per /day, depending on the extent of injury and
degree of physiologic stress.
• Typically, the suggested nonprotein calorie to nitrogen ratio is
approximately 50:1
• in cancer patients, higher levels of stress require increased protein
needs in the range of 80:1 to 100:1.

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Enteral and parenteral nutritional support
• The general rule of thumb for postoperative nutrition favors enteral
access: “If the gut works, use it.”
• Enteral feeding is easily administered, well-tolerated, helps maintain
the barrier mechanism of the gastrointestinal tract, and promotes
mucosal growth and development.
• Enteral nutrition is more efficient, less expensive, and is associated
with fewer metabolic complications like hyperglycemia, cholestasis,
and fatty infiltration of the liver, all of which occur more frequently
when the parenteral route is utilized.

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Nutritional components for wound healing
• water-soluble and fat-soluble vitamins function as cofactors in many
processes involved in wound repair and healing.
• Vitamins C and A, along with several other essential components,
contribute to optimize wound healing and recovery.
• It is critical to administer vitamin C in critically ill or injured patients,
as deficiency can rapidly develop because of minimal vitamin C
stores in the body.
• Patients at risk of developing vitamin C deficiency should receive 1
to 2 g of vitamin C daily to optimize wound healing

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• Higher tissue concentrations of vitamin A increases recruitment of
macrophages into wounds, leading to more effective phagocytic
activity and cell-mediated immunity.
• Vitamin A deficiency leads to decreased collagen synthesis and
cross-linking, decreased epithelialization, and slower rate of wound
closure.
• Patients with severe injuries, malabsorption, or malnutrition are at
risk of vitamin A deficiency and should receive dietary supplement
of 25,000 IU/day of vitamin A.

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• Although the contributions of vitamin E are not clearly defined, it is
likely that it contributes toward the wound healing process.
• Zinc deficiency leads to decreased DNA and RNA synthesis, impaired
protein production, and decreased cell proliferation:
• in zinc-deficient animals, wound granulation tissue contains lower
concentrations of collagen and noncollagenous proteins.
• As with vitamin C, zinc supplementation has no therapeutic value
unless a true zinc deficiency exists

59
Deep vein thrombosis
• Presentation may be silent (60%) or as a clinical syndrome (40%)
with calf pain and tenderness, oedema of the leg and/or pain on
dorsiflexion of the foot (Homan's sign).
• Ultrasonography and duplex scanning with Doppler ultrasound have
a sensitivity and specificity greater than 90%.

60
• heparin i.v. in a dose of 20,000-30,000 units per day.
• APTT is kept at 1.5-2.5 times the control value.
• Heparin therapy is continued for 5-7 days and is replaced by oral
vitamin K antagonists such as warfarin.
• The dose of warfarin is adjusted according to the thromboplastin
time with reference to an international standard (INR).
• Heparin is discontinued when full anticoagulation has been achieved
and the warfarin is continued for 3-6 months to minimise the risk of
further thrombosis and the development of complications

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Hospital acquired infections
• Hospital-acquired infections are caused by viral, bacterial, and fungal
pathogens; the most common types are bloodstream infection (BSI),
pneumonia (eg, ventilator-associated pneumonia [VAP]), urinary
tract infection (UTI), and surgical site infection (SSI).
• Cancer patients have a higher risk of severe sepsis in comparison
with non-cancer patients, with an increased risk for hospital-
acquired infections (HAI), particularly with multidrug resistant
bacteria (MDRB). The aim of the study is to describe the frequency
and characteristics of HAI and MDRB in critically ill cancer patients

62
• Cancer patients have a 3- to 5-fold greater risk of severe sepsis in
comparison with non-cancer patients, with an increased risk for HAI,
particularly with multidrug resistant bacteria, which are associated
with increased therapeutic failure and high mortality rates.
• Patients with neutropenia or hematological malignancies appear to
be particularly vulnerable to this situation, compared with patients
with solid tumors

63
Risk factors for hospital-acquired infection in cancer patients in a central
Chinese hospital- Xia Zhao et al; 2016

64

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References
• Post operative care of oral and maxillofacial surgery patients- Ogle et
al- oral and maxillofacial clinics of north America; 2006
• Oral cancer pain- dios et al; journal of oral oncology- 2010
• Post operative fluid management- kayiliogu et al; world journal of
critical care medicine; 2015
• Risk factors for hospital-acquired infection in cancer patients in a
central Chinese hospital- Xia Zhao et al; 2016
• Maintenance of mouth hygiene in patients with oral cancer in the
immediate post-operative period -A Chandu; Australian Dental
Journal 2002

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• Post-Operative Drop in Hemoglobin and Need of Blood Transfusion
in Cesarean Section at Dhulikhel Hospital, Kathmandu University
Hospital- Singh; kathmandu university medical journal; 2013
• Transfuse or Not to Transfuse: For Post-op Anemia - Jasmine Chao-
American Journal of Clinical Medicine; 2011
• Current Approaches to Free Flap Monitoring – Chao et al.
• Oral Cancer Malnutrition Impacts Weight and Quality of Life -Nils-
Claudius Gellrich
• Oral cancer in India: An epidemiologic and clinical review - R.
Sankaranarayanan, oral surc oral med oral pathol 1990

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Thank you

Postoperative cancer care

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