Transcript post op. care

Post-operative care
Instructions :
- clear communication ( verbal & written ).
Hemorrhage, edema, nausea& vomiting, starvation, wound hygiene,
rest, nutrition, smoking, alcohol & pain relief.
1 – hemorrhage :
hemostasis& oozing must be achieved at the conclusion of the
surgery& before patient discharge.
stages of hemorrhage :
a- primary: patient should bite on gauze pack for 20-30 minutes,
( repeat if necessary ), otherwise you may need suturing
or inserting a haemostatic agent ( gelfoam or surgicel into
the socket ).
b- reactionary hemorrhage: occurs after 24-48 hours.
Avoid hot foods, hot liquids, vigorous exercise& stress,
fingers& tongue away from surgical site, avoid smoking
& others. If bleeding persists contact specialist or surgeon.
c- secondary haemorrhage: occurs after 8-10 days, often due to
infection.
2- edema : normal reaction of the body to oral surgery.
How to minimize facial swelling ?
- careful surgery, operator experience (reduced operating time).
- ice packs immediately after surgery( theoretically reduce blood
flow).
- the use of steroids to dampen the body inflammatory response,
but steroids best reserved for difficult, prolonged surgical cases.
-dexamethasone 4-8 mg I.V., intraoperatively, then, 4 mg every 8
hours for 24 hours.
- methyleprednisolone 100 mg I.V., intraoperatively, followed by
50-100 mg every 6-8 hours for 24 hours.
- NSAIDS : have failed to demonstrate any ability to reduce
postoperative swelling.
3- nausea & vomiting : mostly after G.A.& this may be due
to ( narcotics, blood in the stomach, starvation ).
narcotics: give antiemetics ( maxolon 10 mg or
stemetil 12.5 mg I.M., 6-8 hours routinely added to
their drug chart. Patients are encouraged to take
fluids, lemonade.
blood in the stomach: reassurance, antacids.
4- starvation: I.V. dextrose or Hartmann’s solution during
surgery under G.A. to maintain fluid, electrolyte&
sugar balance.
5 – wound hygiene :
- oral surgical wounds have no higher incidence of infection
than surgical wounds on the skin. Also, you cannot brush
teeth, so, the best is mouth rinse.
- S.W.M.W. : saline, 4-6 times/day, keep in mouth for two
minutes. It sooths the surgical wound, promotes rapid
healing.
- antiseptic M.W. : 0.2% chlorhexidine ( after each meal ), if
used more than one week , it causes teeth stain.
- better no rinse on the surgery day
6 – rest :
- is part of recovery & this must be emphasized to patient, who is
stressed & exhausted after surgery.
- exercise should be discouraged, especially, in the first 24 hours.
Vigorous exercise, football, rugby, weight-lifting should be delayed
for 3-4 weeks.
- sick leave: this depends on the complexity of the surgery& the type
of work the patient is engaged in & not on the patient request.
7 – nutrition :
- benefits of adequate nutrition: increase body immunity,
resistance to infection,& improve wound healing.
- limitations of diet : pain, swelling, trismus. So, diet is
confined to: soft food& or processed solid food,
lemonade, fruit juices fortified with vitamins& minerals, milk.
Broth from pharmacy.
8 - smoking & alcohol: in addition to general health hazards, these
may cause: increased potential for reduced healing ( delayed
healing), for wound infection (dry socket ), postoperative
bleeding, especially, in chronic alcoholism. Also, decreased
immune capacity.
- respiratory complication, when under G.A.
- adverse drug interaction between alcohol& postoperative
medications (e.g.) narcotic analgesics, antibiotics such as
metronidazole. Patients advised to abstain from smoking &
alcohol during recovery period.
9 – Pain relief :
- pain is a subjective phenomenon, depends on complexity of
the surgery & patient’s response to pain, (clinician must
distinguish between pain relief & control).
- selection : the choice of analgesics depend on the following
factors : history of allergy, patient tolerance of the
medication, complexity of the surgery,& cost.
- prescription: (take as required philosophy ), provides brief
periods of relief. Now, it is acceptable to take analgesics at
regular intervals for a certain period of time.
Types of analgesics : mild, moderate, strong for severe pain.
A - NSAIDS : are effective for mild to moderate pain arising
from superficial tissues ( skin, mucosa, joints). The most
common used drugs :
1 – aspirin: rapidly metabolized in liver& plasma.
effective in acute pain of an inflammatory nature
including surgery.Now, mainly used in painful arthritis &
as a prophylaxis against vascular occlusive disease.
Continuation :
paracetamol (acetaminophen) : an alternative to
aspirin, analgesic & antipyretic but with weak antiinflammatory activity.safe in children, elderly,& in
pregnancy (except in first trimester). No gastric
irritation or interference with platelet function.Side
effect : hepatotoxic.
Dose : 500 mg 1-2 tablets 4-hourly (>4g/day ).
Ibuprofen : It is gaining popularity as a first choice
analgesic following M.O.S.( analgesic & antiinflammatory effect ).Less gastric irritation.
Dose : 400-600 mg 8-hourly.
Other NSAIDS : indomethacin, naproxen: are rarely
used in M.O.S., because of their longer half-lives & it
is more suitable for chronic inflammatory conditions
rather than acute surgical pain
B-
Narcotics : opiates narcotics act on specific receptors in the
C.N.S.( central analgesic effect, unlike NSAIDS, is not confined
to pain arising from inflammatory process).It dampens patient’s
emotional response to pain rather than eliminating the pain
sensation itself.They still feel pain but are able to tolerate it.
They are more useful for severe pain arising from deep or
visceral structures. Used in combination with NSAIDS.
the most common narcotics used are :
Codeine 30-60 mg every 4-hours
Dextropropoxyphene 50-100 mg every 4-6 hours
Oxycodone 5-10 mg every 6-hours
Hydrocodone 5-10 mg every 6-hours
Side effects :
nausea& vomiting, constipation, hypotension, respiratory
depression. Tolerance after one week, & must increase dose for
the same analgesic effect
N.B. : warn patient of potential drowsiness( driving or operating
machinery ).
C- compound analgesics :
Combination of narcotics & NSAIDS will give greater analgesia
by use of smaller doses (e.g.) :
- aspirin 325 mg+ codeine 30 mg 1-2 tablets 4-hourly
- paracetamol 500 mg + codeine 8 mg 1-2 tablets / 4-hourly
- paracetamol 500 mg + codeine 30 mg 1-2 tablets / 4-hourly
- paracetamol 500 mg + hydrocodone 5 mg 1-2 tablets
/ 4-6hours.
Intraoperative analgesics :
maximum intensity of pain after 3-hours. so, commence
analgesia intraoperative & you get effective analgesia after
surgery (e.g.) long-acting local anesthesia drug before the end
of surgery.
Intraoperative narcotics & NSAIDS are less effective than L.A.
Hint : bupivacaine (marcain) 0.5% plain or with adrenaline,
2 ml of solution infiltrated in & around surgical site,
intraoperatively, analgesia could last for 8-hours, but some
patients may be concerned about numbness (I.D.N. block).
D- strong analgesics : pethidine & morphine: only for in-patient
( controlled prescription).
Antibiotics: penicillin group, clindamycin.