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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Principal cause of fever – 4Ws1. Wound2. Wind 3. Water 4. Walking5. Wonder drugs

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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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4th W - WalkingShould remind you that a lower limb can be

the source of the fever

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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

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Compound analgesicAspirin + CodeineParacetamol + codeineParacetamol + hydrocodone

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Intraoperative analgesicsAdministration of long-acting local anaesthetic

drug eg marcain.