1. Submitted by
Dr Shijo Dany Kurian
1st yr PG

2.  Postoperative complications may either be
general or specific to the type of surgery
undertaken and should be managed with the
patient's history in mind.
 Common general postoperative complications
include postoperative fever, atelectasis, wound
infection, embolism and deep vein thrombosis
(DVT).
 Specific complications occur in the following
patterns: early postoperative, several days after
the operation, throughout the postoperative
period and in the late postoperative period

4.  IMMEDIATE
 Primary haemorrhage: either starting during
surgery or following postoperative increase in
 blood pressure - replace blood loss and may
require return to theatre to re-explore the
wound.
 Basal atelectasis: minor lung collapse.
 Shock: blood loss, acute myocardial infarction,
pulmonary embolism or septicaemia.
 Low urine output: inadequate fluid replacement
intra-operatively and postoperatively.

5.  Acute confusion: exclude dehydration and sepsis.
 Nausea and vomiting: analgesia or anaesthetic-related;
paralytic ileus.
 Fever
 Secondary haemorrhage: often as a result of
infection.
 Pneumonia.
 Wound or anastomosis dehiscence.
 DVT.
 Acute urinary retention.
 Urinary tract infection (UTI).
 Postoperative wound infection.
 Bowel obstruction due to fibrinous adhesions.
 Paralytic Ileus.

6.  Bowel obstruction due to fibrous adhesions.
 Incisional hernia.
 Persistent sinus.
 Recurrence of reason for surgery - eg,
malignancy.

7.  The following criteria must be fulfilled before a patient
can be discharged from the recovery room
 The patient is fully conscious, responding to voice or
light touch, able to maintain a clear airway and has a
normal cough reflex
 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 preoperative values or should
be at a level commensurate with the planned
postoperative care

8.  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.

10.  The first postoperative assessment should
take place 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
operating department.

11.  The first postoperative assessment should
determine:
 intraoperative history and postoperative
instructions
 circulatory volume status
 respiratory status
 mental status.

12.  The following postoperative treatment and
prophylaxis options 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)

13.  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.

14.  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.
 This assessment is the most complete opportunity to ensure
that the patient is progressing in a satisfactory manner.
 Each daily assessment is an opportunity to modify the
monitoring regimen so as best to provide data for clinical
decision making.

15.  Sepsis (Eg Infection Of Chest, Urinary Tract,
Wound, Intravenous Cannula Site, Or Intra-abdominal
Collection)
 Sedative Drugs
 Hypoxaemia
 Hypercarbia
 Hypoglycaemia
 Acute Neurological Event

16.  Myocardial Infarction
 Urinary Retention
 Alcohol/Drug Withdrawal
 Hepatic Encephalopathy
 Biochemical Abnormality (Eg Urea, Sodium,
Potassium, Calcium, Thyroid Function, Liver
Function).

17.  Days 0-2:
 Mild fever (temperature <38°C) (common):
 Tissue damage and necrosis at the operation
site.
 Haematoma.
 Persistent fever (temperature >38°C):
 Atelectasis: the collapsed lung may become
secondarily infected.
 Specific infections related to the surgery.
 Blood transfusion or drug reaction.

18. Days 3-5:
 Bronchopneumonia.
 Sepsis.
 Wound infection.
 Drip site infection or phlebitis.
 Abscess formation - eg, subphrenic or pelvic,
depending on the surgery involved.
 DVT.

19. After 5 days:
 Specific complications related to surgery
eg; fistula formation.
After the first week:
 Haemorrhage
 Wound infection.
 Distant sites of infection - eg, UTI.
 DVT, pulmonary embolus

20.  Infectious complications are the main causes of
postoperative morbidity in maxillofacial surgery.
 Postoperative incidence has lessened with the
advent of prophylactic antibiotics but multi-resistant
organisms present an increasing
challenge.
 Wound infection: the most common form is
superficial wound infection occurring within the
first week,
 presenting as localised pain, redness and slight
discharge usually caused by skin staphylococci.

21.  Cellulitis and abscesses:
 Most present within the first week but can be
seen as late as the third postoperative week,
even after leaving hospital.
 Present with pyrexia and spreading cellulitis or
abscess.
 Cellulitis is treated with antibiotics.
 Abscess requires suture removal and probing of
the wound but deeper abscess may require
surgical re-exploration. The wound is left open in
both cases to heal by secondary intention.

22.  Gas gangrene is uncommon and life-threatening.
 Wound sinus is a late infectious complication
from a deep chronic abscess that can occur
after apparently normal healing.
 It usually needs re-exploration to remove
non-absorbable suture or mesh, which is
often the underlying cause

23.  Most wounds heal without complications and
healing is not impaired in the elderly unless there
are specific adverse factors or complications.
 Factors which may affect healing rate are:
 Poor blood supply.
 Excess suture tension.
 Long-term steroids.
 Immunosuppressive therapy.
 Radiotherapy.
 Severe rheumatoid disease.
 Malnutrition and vitamin deficiency.

24.  There are no clinical studies to indicate what is normal
with respect to heart rate and blood pressure for
individual patients in the postoperative period.
 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) should restore the
blood pressure and allow time for the cause of the low
blood pressure and heart rate to be deduced.

25.  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

26.  Hypotension is defined as either a systolic
blood pressure of less than 100 mm Hg or as a
fall of at least 25% from the patient’s normal
pressure.
 Hypotension is relatively common
postoperatively and may be drug induced (eg
residual effects
 of anaesthesia, epidural or opioids) or may
represent fluid deficit

27. OBSERVE IF:
 Awake or easily rousable
 Comfortable
 Normal preoperative BP
 Warm
 Well perfused (capillary
refill <2 seconds)
 Heart rate 50-100bpm
 Passing urine (>0.5
ml/kg/hr)
 No obvious bleeding
SEEK FURTHER ADVICE IF:
 Drowsy or unrousable
 Distressed
 Hypertensive
preoperatively
 Cold
 Capillary refill >2 seconds
 Heart rate >100 or <50 bpm
 Oliguric (<0.5 ml/kg/hr)
 Signs of bleeding (drains,
wounds, haematoma)

28.  Hypertension is common in the postoperative
period as a result of a number of factors
including the stress response, pain, anxiety and
failure to continue medication perioperatively.
 Postoperative hypertension is associated with
bleeding, cerebral events and myocardial
ischaemia especially if the heart rate is also
elevated.
 Treatment of Hypertension
 Beta blockers and intravenous (IV) nitrates are
effective for the control of postoperative
hypertension

29.  Myocardial ischaemia in the first 48 hours after an
operation is the single most important predictor of
serious cardiac events (including cardiac death,
myocardial infarction, unstable angina, congestive
heart failure and serious arrhythmias)
 Several studies have demonstrated that beta blockers
are effective in reducing perioperative ischaemia.
 Although caution has been expressed in the general
use of prophylactic beta blockade, reviews suggest
that perioperative blockade reduces the incidence of
both ischaemia and MI in patients undergoing high
risk surgery.

30.  Perioperative MI (PMI) carries a high risk of
both short and long term morbidity. It is
usuallysilent in presentation with non-specific
ECG changes
 Troponin I has been shown to be a sensitive
and specific method for the diagnosis of
PMI,whereasTroponin T has been shown to
be a marker for PMI in patients with CAD or
CAD risk factors undergoing non-cardiac
surgery

31.  Patients on warfarin sodium have increased risk
of haemorrhage in the perioperative period.
 Warfarin sodium should normally be
discontinued preoperatively and restarted as
soon as is deemed safe postoperatively
 The guideline suggests that after warfarin
sodium therapy is restarted following surgery it
takes about three days on average for the
international normalised ratio (INR) to increase
above 2.0.

32.  Causes :
 Anaesthetic-impaired thermoregulation
 Cold operating environments
 Open body cavities
 Administration of unwarmed IV fluid.
 Management:
 Forced air warming technique (reduces
cardiac events)

33.  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
 Early recognition of developing respiratory
complications with appropriate interventions
may improve outcome

34.  The generally accepted diagnostic criteria for respiratory failure,
pulmonary infections, acute respiratory distress syndrome (ARDS) and
acute lung injury are as follows:
 Respiratory failure
 Type 1 PaO2 < 8kPa (60 mm Hg), PaCO2 <6.6kPa (50 mm Hg)
 Type 2 PaO2< 8kPa (60 mm Hg), PaCO2>6.6kPa (50 mm Hg).
 Atelectasis
 Pulmonary collapse clinically or on X-ray which may be subsegmental,
segmental, lobar or
 pulmonary, without evidence of respiratory infection.
 Respiratory infection
 Any two of the following on two or more days:
 Pyrexia >38
 Positive sputum culture
 Positive clinical findings
 Abnormal chest X-ray – Atelectasis/infiltrates.

35.  Acute respiratory distress syndrome and acute
lung injury:
 Acute onset
 Bilateral infiltrates on chest radiography
 Pulmonary artery capillary wedge pressure
(PACWP) =18 mm Hg or the absence of clinical
evidence of left heart failure
 Acute lung injury is considered to be present if
PaO2(kPa) <_ 40
 ARDS is considered to be present if
PaO2 (kPa) <_ 26.

36.  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.

37.  Up to 4.5% has been reported in adults; higher in children.
 Sterile inflammation of the lungs from inhaling gastric
contents.
 Presents with a history of vomiting or regurgitation with
rapid onset of breathlessness and wheezing.
 A non-starved patient undergoing emergency surgery is
particularly at risk.
 It may be of help to avoid this by crash induction
technique and use of oral antacids or metoclopramide.
 Mortality is nearly 50% and requires urgent treatment
with bronchial suction, positive pressure ventilation,
prophylactic antibiotics and IV steroids

38.  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.
 It requires intensive care with mechanical
ventilation with positive end pressure.

39.  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.

40.  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.
 In normally hydrated patients humidification is
unnecessary.
 Failure to maintain an SpO2 >90% or PaO2>8.0 kPa is
an indication to consider assisted ventilation

41.  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

42.  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 surgery

43.  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

44.  polyuric renal failure
 hyperventilation
 pyrexia
 nasogastric aspirate
 haemorrhage
 inappropriate use of diuretics

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

46.  Excessive fluid administration due to:
 over estimation of loss (drain or third space
losses)
 failure to recognise deteriorating renal function
 failure to recognise deteriorating cardiac
function.
 Volume overload can lead to pulmonary and
tissue oedema.
 Pulmonary oedema can be immediately life
threatening.
 Tissue oedema can lead to poor tissue perfusion,
failure to absorb enteral feed, and failure to eat.

47.  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.

48.  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.
 Dopamine should not be used to treat
oliguria or to prevent renal failure

49.  Antidiuretic hormone (ADH) secretion is increased
after surgery and if excess water is given (as 5%
dextrose) then hyponatraemia may be induced.
 If hyponatraemia is associated with volume depletion
then there must be a degree of sodium deficiency.
 The estimation of the degree of volume excess or
volume depletion requires clinical assessment in
addition to biochemical estimates.
 Very low levels of serum sodium (110-120 mmol/L or
less) can produce symptoms such as stupor, coma or
fits and constitute a medical emergency

50.  Hypernatraemia most commonly indicates a
total body deficiency of water and is an
indication for prompt assessment and
intervention, especially when levels exceed
155 mmol/L

51.  True potassium deficiency in postoperative
patients may result from:
 inadequate replacement
 renal losses
 endocrine abnormalities
 upper and lower GI losses (the actual loss of
potassium from the upper GI tract is small, but
the loss of chloride causes alkalosis which
promotes the movement of potassium into cells
and increases renal excretion).

52.  The clinical effects of hypokalaemia include
skeletal muscle weakness, ileus, and cardiac
arrhythmias. It can also potentiate the
adverse effects of digoxin.
 It is seldom necessary to replace potassium at
a rate of greater than 10-20 mmol/hr.
 Concentrated solutions of potassium are
intensely irritant to peripheral veins and can
cause tissue necrosis if they extravasate.

53.  Emergency treatment of hyperkalaemia:
 IV calcium chloride, which must be titrated
slowly,
 IV calcium gluconate,
 Nebulised beta agonists (such as salbutamol)
 IV 50 ml 50% dextrose with 10 units of short
acting insulin.

54.  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.

55.  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
ECF

56.  buffer systems consists of a weak acid or base and the
salt of that acid or base
 Henderson-Hasselbalch equation, which defines the
pH in terms of the ratio of the salt and acid:
 pH = pK + log BHCO3 / H2CO3 = 27 mEq/L / 1.33
mEq/L = 20 / 1 = 7.4
 As long as the 20:1 ratio is maintained, regardless
of the absolute values, the pH will remain at 7.4

57.  Four types of acid-base disturbances
 combinations of respiratory and metabolic changes
may represent:
▪ compensation for the initial acid-base disturbance
or,
▪ two or more coexisting primary disorders
 10-mmHg PaCO2 change yields a 0.08 pH change

58.  retention of CO2 secondary to decreased alveolar ventilation
 management involves prompt correction of the pulmonary
defect, when feasible, and measures to ensure adequate
ventilation
 prevention: tracheobronchial hygiene during the
postoperative , humidified air, and avoiding oversedation

59.  PaCO2 should not be below 30 mmHg
 dangers of a severe respiratory alkalosis are
those related to potassium depletion
 hypokalemia is related to entry of potassium ions into the
cells in exchange for hydrogen and an excessive urinary
potassium loss in exchange for sodium
 shift of the oxyhemoglobin dissociation curve
to the left, which limits the ability of
hemoglobin to unload oxygen at tissues

60.  Anion gap is a useful aid:
 normal value is 10 to 15 mEq/L
 unmeasured anions that account for the “gap”
are sulfate and phosphate plus lactate and
other organic anions
 measured ions are sodium, bicarb, and
chloride

61.  treatment of metabolic acidosis should be directed
toward correction of the underlying disorder
 sodium bicarbonate is discouraged, attempt to treat
underlying cause
 shifts the oxyhemoglobin dissociation curve left
 interference with O2 unloading at the tissue level

62.  common surgical patient has hypochloremic,
hypokalemic metabolic alkalosis resulting from
persistent vomiting or gastric suction in the patient
with pyloric obstruction
 unlike vomiting with an open pylorus, which involves
a combined loss of gastric, pancreatic, biliary, and
intestinal secretions

63.  majority of the 1000 to 1200g of calcium in the
average-sized adult is found in the bone
 Normal daily intake of calcium is 1 to 3 gm
 Most is excreted via the GI tract
 half is non-ionized and bound to proteins
 ionized portion is responsible for neuromuscular
stability

64.  signs & symptoms (serum level < 8):
 numbness and tingling of the circumoral region
and the tips of the fingers and toes
 hyperactive tendon reflexes, positive Chvostek's
sign, muscle and abdominal cramps, tetany with
carpopedal spasm, convulsions (with severe
deficit), and prolongation of the Q-T interval on
the ECG

65.  causes:
▪ acute pancreatitis, massive soft-tissue
infections (necrotizing fasciitis), acute and
chronic renal failure, pancreatic and small-bowel
fistulas, and hypoparathyroidism

66.  signs & symptoms:
 CNS: easy fatigue, weakness, stupor, and
coma
 GI: anorexia, nausea, vomiting, and weight
loss, thirst, polydipsia, and polyuria

67.  two major causes:
 hyperparathyroidism and cancer
 bone mets
 PTH-like peptide in malignancies

68.  total body content of magnesium 2000 mEq
 about half of which is incorporated in bone
 distribution of Mg similar to K+, the major portion
being intracellular
 normal daily dietary intake of magnesium is
approximately 240 mg
 most is excreted in the feces and the remainder in
the urine

69.  causes:
 starvation, malabsorption syndromes, GI
losses, prolonged IV or TPN with
magnesium-free solutions
 signs & symptoms:
 similar to those of calcium deficiency

70.  Symptomatic hypermagnesemia, although
rare, is most commonly seen with severe
renal insufficiency
 signs & symptoms:
 CNS: lethargy and weakness with progressive loss
of DTR’s – somnolence, coma, death
 CVS: increased P-R interval, widened QRS
complex, and elevated T waves (resemble
hyperkalemia) – cardiac arrest

71.  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.

72.  This may be caused by antibiotics, obstructive
jaundice and surgery to the aorta.
 It is often due to an episode of severe or
prolonged hypotension.
 It presents as low urine output with adequate
hydration.
 Mild cases may be treated with fluid restriction
until tubular function recovers. However, it is
essential to differentiate it from pre-renal failure
due to hypovolaemia which requires rehydration.

73.  In severe cases haemofiltration or dialysis
may be needed while function gradually
recovers over weeks or months.
 One study found that factors predictive of
acute kidney injury included advanced age,
liver disease, high-risk surgery and peripheral
vascular disease.

74.  Sepsis is the systemic inflammatory response to
infection leading to a generalised inflammatory
reaction in organs remote from the initial insult
and eventually to end-organ dysfunction and/or
failure
 Early identification,immediate resuscitation,
identifying the primary source, use of early and
appropriate antibiotics and undertaking
appropriate surgical drainage are the mainstays
of treatment

75.  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
 respiratory rate >20 breaths/min or
PaCO2<4.3kPa
 white cell count >12,000 cells/mm3 , <4,000
cells/mm3, or >10% immature forms.

76.  Prophylactic antibiotics should be administered
to appropriate groups of patients to reduce the
risk of developing postoperative sepsis
 Hand washing with soap and water or with
alcoholic cleansing agents should be performed
before and after patient contact.
 Strict hand antisepsis must be achieved before
the performance of invasive procedures such as
surgery or the placement of intravascular
catheters and indwelling urinary catheters.

77.  Fever/hypothermia
 Unexplained tachycardia
 Unexplained tachypnoea
 Signs of peripheral vasodilation
 Unexplained hypotension/shock
 Changes in mental state
 Leucocytosis/neutropenia
 Unexplained alteration in renal or liver function
 Thrombocytopenia/ disseminated intravascular
coagulation
 Metabolic acidosis

78.  severity of sepsis may be assessed by looking
for organ dysfunction which may be 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.

79.  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.
 It is important that fungi and atypical organisms
can also contribute to sepsis syndrome
 Surgical intervention in the form of debridement
or drainage of infected, devitalised tissue should
be undertaken as soon as possible following
haemodynamic stabilisation

80.  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

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

82.  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

83.  Thank you....