POST-OPERATIVE

COMPLICATIONS
DATO’ DR RUSDI ABD RAHMAN
DEPARTMENT OF ORAL MAXILLOFACIAL SURGERY
HRPZ II

Wednesday, December 08, 2021 1

POST OPERATIVE CONCERNS
1. Fever
2. Hemorrhage
3. Cardiac complications
4. Nausea and vomiting
5. Urinary retention
6. Wound care
7. Pain

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 FEVER
Low grade fever is a common sequel
Fever under 38°C is not significant
Higher demand evaluation
1st 24 hours:
Pulmonary atelectasis
Aspiration pneumonia
Ill defined response to surgery

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 Cont
Between 24 – 72 hours:
Pulmonary atelectasis
Bacterial pneumonia
Thrombophlebitis
After 72 hours:
Pneumonia
Pulmonary embolism
IV catheter infection
Infection of the wound or urinary tract
Blood product transfusion
Drugs

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 Principal cause of fever – 4Ws
1. Wound
2. Wind
3. Water
4. Walking
5. Wonder drugs

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 1st W - Wound
Tissue 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

Wednesday, December 08, 2021 6

 IV site
Possible source
In place for > 24 hours must be suspected
IV lines should be moved to a new site after 72 hours
Signs and symptoms:
Pain
Tenderness
Edema
Erythema
Streaking on the limb

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 Cont
Treatment:
1. Remove IV line
2. Elevates the limb
3. Apply warm and moist packs
4. Antibiotics
5. If the result of blood culture is positive – refer to ID
specialist

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Breakdown in aseptic technique
Wound infection become apparent between
postoperative days 3 and 7
Look 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 qid
Immunologically compromised patient - imipenem

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 2nd W - Wind
Respiratory complications cause a quarter of all
postoperative death
Most frequent respiratory complication in OMFS:
Pulmonary atelectasis
Aspiration pneumonia
Pulmonary embolus

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 Pulmonary atelectasis
Imperfect expansion of the lung in a small area of alveoli
Base-of-lung segments
Usually in patient who smoke
Usualy begin within 24 – 48 hours
Causes:
Use of cuffed endotracheal tubes
Depressed mucosalivary clearance due to the drying effect of the
gases
Long period of preoperative fasting > dehydration
Prolonged anesthesia
Depression 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 dyspnea

Chest radiograph for evaluation – to exclude pneumonia
and segmental collapse
Pneumonia > antibiotic therapy
Segmental collapse > bronchoscopic evaluation and
referral

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 Aspiration pneumonia
Inhalation of foreign material
Causes:
Poor throat pack seal
Uncuff ET tube
Depression of cough reflex
During sedative therapy
IMF
Frequent in right lung
Fever as early as 3 - 5 days or as late 2 – 3 weeks after
surgery
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 Cont
Presentations
Malaise, cough, sputum production, pleuritic pain
Treatment
Appropriate specialist
High doses of AB, eg Timentin

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 Pulmonary embolus
Blood clot lodged in the pulmonary artery or one of its
branches.
The clot formed peripherally, broke free and become
trapped in the pulmonary vascular circulation
Prevention – ambulate early
Usually, 5 – 10 days precede the the development
Chief cause – Virchow’s triad
1. Damage to the endothelial lining
2. Stasis or diminution in the rate of flow
3. change in the blood contituents due to a postop increase in
the number and adhesiveness of the platelet
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 Cont
Clinical features – fever, chest pain, sudden dyspnea,
tachypnea, hemoptysis
Confirmation – ventilation perfusion lung scan,
pulmonary angiography. Noninvasive – US imaging,
impendance plethysmography
Treatment
1. Limb elevation
2. Systemic anticoagulant
3. Oral anticoagulant
4. Thrombolytic therapy – to be avoided

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 3rd W - Water
Caused by an indwelling catheter or intermittent
catheterization
Women are at greater risk because of the short female
urethra
The 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 - Walking
Should remind you that a lower limb can be the source
of the fever

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 5th W – Wonder drugs and transfusion
Many drugs have been implicated
Bacterial etiology should be rule-out before the fever
is attributed to medication
How?
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

Wednesday, December 08, 2021 19

 Transfusion
A common source of fever
Mild febrile reaction – NTR
Fever with tachycardia, chills, back pain, dyspnea, micro
vascular bleeding > a major transfusion reaction must be
suspected
Treatment
Stop the transfusion
Patients blood should be cross matched again
Should hemolysis occur, patient will required forced diuresis
and alkalization of the urine to prevent renal toxicity.

Wednesday, December 08, 2021 20

 Nausea and vomiting
More frequent in children than adult
Women > men
Obese
Motion sickness
The longer the op, the greater the likelihood that there will be operative
nausea and vomiting
 Causes
Starvation
Blood in the stomach
Drugs
 Narcotics, metronidazole etc
Hypotension
Hypoxia

Wednesday, December 08, 2021 21

 Cont
Narcotic analgesics is a common cause
If this occur, changed to NSAIDS alone
Pt on narcotics following surgery must be given
antiemetics such as:
metoclopramide (Maxolon) 10 mg IM qid
Prochlorperazine (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.

Wednesday, December 08, 2021 22

 Pain
Subjective phenomena
Difficult to measure objectively
Dependent on the complexities of surgery
Dependent on the pt’s individual response to pain (pain
threshold)
Essential part of the postoperative care
Must must be pain-free postoperatively
Prescribed analgesics generously
Selection based on
Patient tolerance
History of allergy
Complexity of the surgery
Cost
Wednesday, December 08, 2021 23
 Cont
Take as required philosophy PRN
Brief periods of relief
More frequent pain cycles
Decreased analgesic effectiveness
Overuse of the medication
Abuse of the medication
More acceptable practice
Regular interval – bd, tds, qid
For a specific period of time
Until which sufficient symptomatic relief is achived so that it is no longer
required
Analgesic taken at regular interval
Reduce the likelihood of intolerable pain
Improve post-op comfort
Promote a more rapid recovery
Wednesday, December 08, 2021 24
 NSAIDs
Most commonly prescribed
For mild to moderate pain arising from inflammatory
process
Eg
Aspirin
Paracetamol
Ponstan
Voltaren

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 Narcotics
Act on specific receptors in CNS conferring a central
analgesic effect
Not confined to pain arising from inflammatory
process
More 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 analgesic
Aspirin + Codeine
Paracetamol + codeine
Paracetamol + hydrocodone

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 Intraoperative analgesics
Administration of long-acting local anaesthetic drug eg
marcain.

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