General care of the surgical patient

1. General CareGeneral Care
of the SurGiCalof the SurGiCal
PatientPatient
PRESENTERPRESENTER
E.DIVYA JYOTHIE.DIVYA JYOTHI
II YR PGII YR PG

2. ContentSContentS
 IntroductionIntroduction
 Phases of the surgeryPhases of the surgery
 Preoperative phase.Preoperative phase.
 Intraoperative phaseIntraoperative phase
Triad of general anesthesiaTriad of general anesthesia
General anesthetic agentsGeneral anesthetic agents
Need for G.A in OMFSNeed for G.A in OMFS
AdvantagesAdvantages
DisadvantagesDisadvantages
Intraoperative complicationsIntraoperative complications

3.  Postoperative phasePostoperative phase
 Follow upFollow up
 conclusionconclusion

4. introduCtionintroduCtion
 Many patients requiring major inpatient electiveMany patients requiring major inpatient elective
surgery in maxillofacial surgery. The oral &surgery in maxillofacial surgery. The oral &
maxillofacial surgeon must know both physical andmaxillofacial surgeon must know both physical and
emotional status of a patient, which is significant foremotional status of a patient, which is significant for
apparently healthy patients undergoing simple surgicalapparently healthy patients undergoing simple surgical
procedures as well as for hospitalized patients &procedures as well as for hospitalized patients &
medically compromised patients with complex surgicalmedically compromised patients with complex surgical
problems. A sound medical knowledge is of greatestproblems. A sound medical knowledge is of greatest
important in patient managementimportant in patient management

5. PhaSeSPhaSeS
 Preoperative PhasePreoperative Phase: The period of time from when: The period of time from when
decision for surgical intervention is made to when thedecision for surgical intervention is made to when the
patient is transferred to the operating room table.patient is transferred to the operating room table.
 Intraoperative PhaseIntraoperative Phase:: Period of time from when thePeriod of time from when the
patient is transferred to the operating room table topatient is transferred to the operating room table to
when he or she is admitted to the post anesthesia carewhen he or she is admitted to the post anesthesia care
unit.unit.

6.  Postoperative PhasePostoperative Phase: Period of time that begins with the: Period of time that begins with the
admission of the patient to the post anesthesia care unitadmission of the patient to the post anesthesia care unit
and ends after follow-up evaluation in the clinicaland ends after follow-up evaluation in the clinical
setting or home.setting or home.
 Perioperative Period:Perioperative Period: Period of the time that constitutePeriod of the time that constitute
the surgical experience, include the preoperative,the surgical experience, include the preoperative,
intraoperative, postoperative phasesintraoperative, postoperative phases

7. PreoPerative PhaSePreoPerative PhaSe
 Gather & record concisely all relevant information.Gather & record concisely all relevant information.
 Devise a plan to minimize risk & maximize benefits for theDevise a plan to minimize risk & maximize benefits for the
patient.patient.
 Consider possible adverse events and plan how to deal withConsider possible adverse events and plan how to deal with
them .them .
 Note previous anesthetics, with complications or unexpectedNote previous anesthetics, with complications or unexpected
outcomes (post operative nausea and vomiting)outcomes (post operative nausea and vomiting)
 Any family history of anesthetic problems.Any family history of anesthetic problems.

8.  Systematically enquire about present and past medical historySystematically enquire about present and past medical history
and current medications.and current medications.
 Assess general health.Assess general health.
 Rule out previous or current usage of drugs and drugRule out previous or current usage of drugs and drug
allergies .allergies .
 Social historySocial history: Establish smoking & alcohol intake. Patient: Establish smoking & alcohol intake. Patient
with a history of alcohol abuse may have liver dysfunctionwith a history of alcohol abuse may have liver dysfunction
and be relatively resistant to the effect of sedative drugsand be relatively resistant to the effect of sedative drugs

9.  Surgical patientsSurgical patients
 In-patientIn-patient
 Out-patientOut-patient

10. PreoPerative aSSeSSmentPreoPerative aSSeSSment

11. Pre-oPerativePre-oPerative inveStiGationSinveStiGationS
• Patient undergoing surgery should be screened forPatient undergoing surgery should be screened for
• BiochemicalBiochemical
• HematologicalHematological
• Radiological abnormalitiesRadiological abnormalities

12. BioChemiCalBioChemiCal

13.  Blood glucoseBlood glucose ::
 Normal values 65-110 mg/100mlNormal values 65-110 mg/100ml
 To rule out metabolic disorders(diabetics).To rule out metabolic disorders(diabetics).
 Patients are at high risk of complicationsPatients are at high risk of complications
 Preoperatively cardiovascular, neurological status should bePreoperatively cardiovascular, neurological status should be
assessed.assessed.
 I.V insulin will be required for pts (insulin dependent) startsI.V insulin will be required for pts (insulin dependent) starts
when pt first omits meal until recovered from surgery.when pt first omits meal until recovered from surgery.
 Patients on metformin (risk of lactic acidosis ) drug should bePatients on metformin (risk of lactic acidosis ) drug should be
discontinued 24 hrs before restarted 24-48 hrs after surgery.discontinued 24 hrs before restarted 24-48 hrs after surgery.

14.  Glycocylated hb:Glycocylated hb:
 Refers to glucose derivatives of normal adult hb(hbA)Refers to glucose derivatives of normal adult hb(hbA)
 DIAGNOSTIC IIMPORTANCE:DIAGNOSTIC IIMPORTANCE:
 Directly related to exposure of RBC to glucose.Directly related to exposure of RBC to glucose.
 Is an indication of blood glucose concentration over a period.Is an indication of blood glucose concentration over a period.
(6-8 wks)(6-8 wks)
 Normal concentration is about 3-5% ot total hb.Normal concentration is about 3-5% ot total hb.
 Reflects the mean blood glucose level over 2 months periodReflects the mean blood glucose level over 2 months period
prior to its measurement.prior to its measurement.

15.  Serum Urea :Serum Urea :
 Normal values :2.5-8 mg/100ml.Normal values :2.5-8 mg/100ml.
 Normally necessary in patients over 65 yrs .Normally necessary in patients over 65 yrs .
SignificanceSignificance--
 In patients who may lose a significant amount of blood inIn patients who may lose a significant amount of blood in
theater,theater,
 With history of cardiovascular ,pulmonary ,renal problems.With history of cardiovascular ,pulmonary ,renal problems.
 In those taking diuretics & aspirin (hyperuricemia ).In those taking diuretics & aspirin (hyperuricemia ).
 when hyperuricemia is associated withwhen hyperuricemia is associated with
hypercholesterolemia the incidence of MI is increased.hypercholesterolemia the incidence of MI is increased.

16.  Electrolytes:Electrolytes:
 SodiumSodium::
 Normal values:Normal values:135-145 meq/l135-145 meq/l
 Hyponatremia is associated withHyponatremia is associated with
 HypernatremiaHypernatremia is associated withis associated with
 CirrhosisCirrhosis
 Congestive heart failureCongestive heart failure
 Adrenal insufficiencyAdrenal insufficiency
 NephrosisNephrosis
 Excessive use of diureticsExcessive use of diuretics
 VomitingsVomitings
 DiarrheaDiarrhea
 Severe sweating.Severe sweating.
 Diabetes mellitusDiabetes mellitus

17.  PotassiumPotassium::
 Normal values:3.2-5.5 meq/lNormal values:3.2-5.5 meq/l
 Hypokalemia is associated withHypokalemia is associated with
 Hyperkalemia is associated withHyperkalemia is associated with
 Inadequate intake orInadequate intake or
losses from GIT orlosses from GIT or
urinary tractsurinary tracts
 VomitingsVomitings
 DiarrheaDiarrhea
 Use of diureticsUse of diuretics
 Release of cellularRelease of cellular
potasium secondarypotasium secondary
to surgeryto surgery
 Crush injuriesCrush injuries

18.  Hemolysis of RBCsHemolysis of RBCs
 Renal failureRenal failure
 AcidosisAcidosis
Choride:
Normal values:95-105 meq/l
Serum chloride levels usually follow those for
serum sodium
Cloride will be reduced in vomitings

19.  Serum calcium:Serum calcium:
 Normal values:8.5-10.5 mg/100mlNormal values:8.5-10.5 mg/100ml
 Increased levels indicatesIncreased levels indicates
 Decreased levels indicatesDecreased levels indicates
 HyperparathyroidismHyperparathyroidism
 Malignancy withMalignancy with
bone metastasisbone metastasis
 HypoparathyroidismHypoparathyroidism
 TenanyTenany
 HypoalbunemiaHypoalbunemia
 Renal failuresRenal failures
 StarvationStarvation

20.  Serum creatinine:Serum creatinine:
 Normal values:0.7-1.4 mg/100mlNormal values:0.7-1.4 mg/100ml
 It is the most sensitive indicator of GFR(inversely varies)It is the most sensitive indicator of GFR(inversely varies)
 Increased levels indicatesIncreased levels indicates Impaired kidneyImpaired kidney
functionfunction
 Muscle diseasesMuscle diseases

21.  Serum cholestrolSerum cholestrol::
 Normal values: 150-300 mg/100mlNormal values: 150-300 mg/100ml
 Increased levels indicatesIncreased levels indicates
 NephrosisNephrosis
 Chronic obstructiveChronic obstructive
biliary diseasebiliary disease
 HypothyroidismHypothyroidism
 DiabetesDiabetes
Decreased levels indicates
 HyperthyroidismHyperthyroidism
 MalnutritionMalnutrition
 Severe liver damageSevere liver damage

23.  HemoglobinHemoglobin::
 Normal values: Females- 12-16 gm%Normal values: Females- 12-16 gm%
Males-14-18 gm%Males-14-18 gm%
SIGNIFICANCE:SIGNIFICANCE:
Patients undergoing elective surgery with a preoperative (Hb)Patients undergoing elective surgery with a preoperative (Hb)
less than or equal to 120 g/L are at a high risk of bloodless than or equal to 120 g/L are at a high risk of blood
transfusion.transfusion.
As anemia worsens ,demand for oxygen exceeds resulting inAs anemia worsens ,demand for oxygen exceeds resulting in
hypoxia ,end organ injury.hypoxia ,end organ injury.

24. PreoPerative red Blood Cell tranSfuSionPreoPerative red Blood Cell tranSfuSion
CriteriaCriteria
Hb level
(g/dl)
Indication
<6 Probably benefit from transfusion
6-8 Transfusion unlikely to be benefit in the absence of
bleeding or impending surgery
>8 No indication for transfusion

25. tranSfuSiontranSfuSion
Type of
transfusion
Indication
Warm blood Cardiopulmonary operations
Auto transfusion Patients undergoing elective surgery
Exchange/replacemen
t transfusion
New born infants with erythroblastosis foetalis
Packed red cells Chronic anemia
Elders
Patients whose cardiac reserve is low
Fresh frozen plasma Coagulation deficiencies
Liver diseases
Vit.K deficiency
Platelet rich plasma Thrombocytopenic purpura

26.  One must always consider iron and multivitamin therapyOne must always consider iron and multivitamin therapy
preoperatively to optimize hb synthesis .preoperatively to optimize hb synthesis .
 Therapeutic doses of iron should increase hemoglobin levelsTherapeutic doses of iron should increase hemoglobin levels
byby 0.7-1.0g/dl per week0.7-1.0g/dl per week..
 500 ml of stored blood transfusion will generally raise Hb%500 ml of stored blood transfusion will generally raise Hb%
by 10%by 10%

27.  Hematocrit:Hematocrit:
 Normal values : Females -37-47%Normal values : Females -37-47%
Males -40-52%Males -40-52%
 It is a measurement of packed red cell volume .It is a measurement of packed red cell volume .
 Valuable in evaluating polycythemia , anemia, blood lossValuable in evaluating polycythemia , anemia, blood loss

28.  Total RBC count:Total RBC count:
 Normal values : females -4.5- 5.5 million/mm3Normal values : females -4.5- 5.5 million/mm3
Males -4.5-6.2 million/mm3Males -4.5-6.2 million/mm3
 Provides gross estimation of body oxygen carrying capacityProvides gross estimation of body oxygen carrying capacity
 Used in figuring the red cell indices for diagnosis of variousUsed in figuring the red cell indices for diagnosis of various
types of anemiastypes of anemias

29.  Total WBC count:Total WBC count:
 Normal values : 5000-10,000 cells/mm3Normal values : 5000-10,000 cells/mm3
 Valuable in dealing with infectionsValuable in dealing with infections
 Differential count: Normal distibution of WBCs as followsDifferential count: Normal distibution of WBCs as follows
Nutrophils 50-70%
Lymphocytes 25-40%
Monocytes 3-8%
Eosinophils 1-4%
Basophils 0-1%

30.  ESR:ESR:
 It is a nonspecific testIt is a nonspecific test
 Normal values –Females- 0-20mm/hrNormal values –Females- 0-20mm/hr
Males-0-10 mm/hrMales-0-10 mm/hr
 Above normal indicates infections, infarctions,or tumorsAbove normal indicates infections, infarctions,or tumors

31.  C-reactive proteinC-reactive protein ((CRPCRP)):)):
 Pentameric found in bloodfound in blood
 Levels raise in response to inflammationLevels raise in response to inflammation
 CRP is used mainly as a marker of inflammationCRP is used mainly as a marker of inflammation
 Measuring and charting CRP values can prove effectivenessMeasuring and charting CRP values can prove effectiveness
of treatments.of treatments.
 Normal concentration is between 5 and 10 mg/LNormal concentration is between 5 and 10 mg/L
 CRP is a more sensitive and accurate reflection of the acuteCRP is a more sensitive and accurate reflection of the acute
phase response than the ESRphase response than the ESR[[

32. radioloGiCalradioloGiCal

33.  CHEST X-RAY: Required in patients with significantCHEST X-RAY: Required in patients with significant
cardiac history (HTN), respiratory problemscardiac history (HTN), respiratory problems
THE SYSTEMATIC APPROACH TO CHEST X-RAYTHE SYSTEMATIC APPROACH TO CHEST X-RAY
 The proposed system for looking at a radiograph of the chestThe proposed system for looking at a radiograph of the chest
involves :involves :
 A-airwayA-airway
 B-boneB-bone
 C-cardiacC-cardiac
 D-diaphragmD-diaphragm
how to read CheSt x-rayhow to read CheSt x-ray

34.  E&F-equal (lung) fieldsE&F-equal (lung) fields
 G-gastric bubbleG-gastric bubble
 H-hilum (and mediastinum).H-hilum (and mediastinum).
 AIRWAY:AIRWAY:
 Look at the trachea and its branches:Look at the trachea and its branches:
 Check the site, size, shape, and shadow (4 S’s).Check the site, size, shape, and shadow (4 S’s).
 Narrowed indicating stenosis.Narrowed indicating stenosis.
 In children it should be straight.In children it should be straight.
 In adults it can deviate to the right due the aortic arch.In adults it can deviate to the right due the aortic arch.

35.  Trachea gets pushed away from abnormality -Trachea gets pushed away from abnormality - pleuralpleural
effusion or tension pneumothoraxeffusion or tension pneumothorax
 Trachea gets pulled towards abnormality -Trachea gets pulled towards abnormality - atelectasisatelectasis
 BONEBONE
 Look at and compare the bony structures (clavicles, ribs,Look at and compare the bony structures (clavicles, ribs,
scapulae, thoracic vertebrae, and humeri).scapulae, thoracic vertebrae, and humeri).
 Interruption of smooth line along edges of each boneInterruption of smooth line along edges of each bone
indicates fractures.indicates fractures.
 Any discrete darker areas or change in bone densityAny discrete darker areas or change in bone density
indicates lytic lesions.indicates lytic lesions.

36.  Any bony deformity (rachitic rosary at the costochondralAny bony deformity (rachitic rosary at the costochondral
joints seen in rickets)joints seen in rickets)
 Lateral deviations of the vertebrae (scoliosis).Lateral deviations of the vertebrae (scoliosis).
 CARDIACCARDIAC
Take note of the cardiac site, size, shape, shadows and borders.Take note of the cardiac site, size, shape, shadows and borders.
 SiteSite
 SizeSize: should be less than half the transthoracic diameter (i.e.: should be less than half the transthoracic diameter (i.e.
is the largest diameter of the heart less than half the largestis the largest diameter of the heart less than half the largest
diameter of the thorax)diameter of the thorax)
 ShapeShape: ovoid with the apex pointing to left.: ovoid with the apex pointing to left.

38.  ShadowsShadows: Any change in density?: Any change in density?
 Borders:Borders: Should be clear or well defined.Should be clear or well defined.
 DIAPHRAGMDIAPHRAGM
 Outline of the diaphragm should be clear and smooth.Outline of the diaphragm should be clear and smooth.
 Right hemidiaphragm should be higher (2-3cm) than the left.Right hemidiaphragm should be higher (2-3cm) than the left.
 Highest point on the right should be in the middle of the rightHighest point on the right should be in the middle of the right
lung field.lung field.
 Highest point on left should be slightly lateral to the middle ofHighest point on left should be slightly lateral to the middle of
the left lung fieldthe left lung field

40.  Deviation may indicate pneumothorax.Deviation may indicate pneumothorax.
 Costophrenic angles should be well defined.Costophrenic angles should be well defined.
 Whiteness immediately above the diaphragm indicates pleuralWhiteness immediately above the diaphragm indicates pleural
effusion or consolidation.effusion or consolidation.
 EQUAL (lung) FIELDS:EQUAL (lung) FIELDS:
 Divide lung fields into zones: upper, middle, and lower zonesDivide lung fields into zones: upper, middle, and lower zones
 Upper:Upper: From the apex to 2nd costal cartilageFrom the apex to 2nd costal cartilage
 MiddleMiddle: Between 2nd and 4th costal cartilage: Between 2nd and 4th costal cartilage
 LowerLower:Between 4th and 6th costal cartilage:Between 4th and 6th costal cartilage

41.  Look for equal radiolucency between the left and the rightLook for equal radiolucency between the left and the right
lungs zones.lungs zones.
 More specifically look for:More specifically look for:
 Air bronchograms , air-filled bronchi, outlined byAir bronchograms , air-filled bronchi, outlined by
surrounding consolidationsurrounding consolidation
 Bat’s wing distributionBat’s wing distribution ::
 Bilateral opacification spreading from the hilar regions intoBilateral opacification spreading from the hilar regions into
the lungs (sparing the peripheral lung areas) signifyingthe lungs (sparing the peripheral lung areas) signifying
extensive alveolar disease.egextensive alveolar disease.eg: Pulmonary edema in heart: Pulmonary edema in heart
failure, fluid overload, blood transfusion reactionfailure, fluid overload, blood transfusion reaction..

42.  Reversed bat’s wing distributionReversed bat’s wing distribution in fat embolism 1-2 daysin fat embolism 1-2 days
following a bone fracture.following a bone fracture.
 Kerley A, B, and C lines which are fine lines running throughKerley A, B, and C lines which are fine lines running through
the lungs representing thickened connective tissue septae seenthe lungs representing thickened connective tissue septae seen
in intersitial pulmonary edema.in intersitial pulmonary edema.
 Kerley A lines - upper lobes.Kerley A lines - upper lobes.
 Kerley B lines - (1-2 cm) in lower lobes.Kerley B lines - (1-2 cm) in lower lobes.
 Kerley C lines are diffusively distributed through the entireKerley C lines are diffusively distributed through the entire
lung.lung.
Associated with cardiac enlargement and pleural effusions.Associated with cardiac enlargement and pleural effusions.

43.  GASTRIC FUNDUSGASTRIC FUNDUS
An air bubble under the left hemidiaphragm.An air bubble under the left hemidiaphragm.
 HILUM AND MEDIASTINUM:HILUM AND MEDIASTINUM:
 Large blood vessels going to and from the lung at the root ofLarge blood vessels going to and from the lung at the root of
each lung where it meets the heart.each lung where it meets the heart.
 Left should be higher than the right.Left should be higher than the right.

44. Specific inveStigationSSpecific inveStigationS
 Liver function tests:Liver function tests:
 Indicated in pts with h/o jaundice, known or suspectedIndicated in pts with h/o jaundice, known or suspected
hepatitis,hepatitis,
 Patients with clotting problems.Patients with clotting problems.
 ECG:ECG:
 Required in pts over 65 yrs.Required in pts over 65 yrs.
 With history of CVS and pulmonary problems.With history of CVS and pulmonary problems.
 By which electrical activity of heart is recordedBy which electrical activity of heart is recorded

45.  ECG paper has horizontal,ECG paper has horizontal,
vertical linesvertical lines
 Duration is denoted by verticalDuration is denoted by vertical
lines.lines.
 Amplitude is denoted byAmplitude is denoted by
horizontal lines.horizontal lines.

46. WaveS anD inteRvaLS of noRMaL ecgWaveS anD inteRvaLS of noRMaL ecg

47. WAVE/SEGMENT CAUSE
P wave Atrial depolarization
QRS complex Ventricular depolarization
T wave Ventricular repolarization
P-R interval Atrial depolarization and conduction thru AV node
Q-T interval Electrical activity of vetricles
S-T segment Isoelectric

48.  Heart rate :Heart rate :
 can be calculated by measuring number of R waves /unit timecan be calculated by measuring number of R waves /unit time
 Number of R waves in 6 sec(30 th thick vertical line) multipliedNumber of R waves in 6 sec(30 th thick vertical line) multiplied
by 10 = heart rate.by 10 = heart rate.
 Rhythm:Rhythm:
 Quickly determined by counting the number of large graphQuickly determined by counting the number of large graph
boxes between two R waves.boxes between two R waves.

50.  HRV is decreased in hypertension ,DMHRV is decreased in hypertension ,DM
 R-R intervalR-R interval is time between two R wavesis time between two R waves
 Significance: duration of 1 cardiac cycle.Significance: duration of 1 cardiac cycle.
 Any deviation from S-T segment indicates pathologyAny deviation from S-T segment indicates pathology
 Elevation in acute M.IElevation in acute M.I
 Depression in myocardial ischemia ,hypokalemia.Depression in myocardial ischemia ,hypokalemia.

51. pRe anaeStHeSticpRe anaeStHeStic
MeDicationMeDication

52. aiMS of pReMeDicationaiMS of pReMeDication
• To allay pre-operative fear and anxiety.To allay pre-operative fear and anxiety.
• To produce amnesia and analgesia.To produce amnesia and analgesia.
• To reduce secretion from salivary glands and respiratoryTo reduce secretion from salivary glands and respiratory
tract.tract.
• To potentiate anesthetic drugsTo potentiate anesthetic drugs
• To depress unwanted reflex vagal activitiesTo depress unwanted reflex vagal activities
• To reduce the pH and volume of gastric contents and riskTo reduce the pH and volume of gastric contents and risk
associated with regurgitation and aspiration.associated with regurgitation and aspiration.
• To attenuate sympathetic reflex activities and stressTo attenuate sympathetic reflex activities and stress
associated with anesthesia and surgery.associated with anesthesia and surgery.
• To reduce incidence of post operative nausea and vomiting.To reduce incidence of post operative nausea and vomiting.

53. pReopeRative DRUgSpReopeRative DRUgS

54. • H2
antagonists
• Ranitidine
• Famotidine
• 150
mg
• 20-40
• Oral, IM
• Oral
• Proton
pump
inhibitors
• Omeprazole • 20-40 • Oral
• Antiemetics
Metoclopramide
• Ondansetron
• 10-20
• 4-8 mg
• Oral,IM, IV
• IV
pReopeRative DRUgSpReopeRative DRUgS

55. npo(nBM)npo(nBM)
 Ensures time for the patient ‘sEnsures time for the patient ‘s
stomach to empty.stomach to empty.
 Reduces risk of vomiting andReduces risk of vomiting and
aspiration on induction if G.Aaspiration on induction if G.A
 Pre-operative fasting in adultsPre-operative fasting in adults
undergoing elective surgery –undergoing elective surgery –
 2-6 rule’:2-6 rule’:
 • ‘• ‘2’ – Intake of water up to 22’ – Intake of water up to 2
h before induction Ofh before induction Of
anesthesia.anesthesia.

56.  • ‘• ‘6’ – A minimum pre-operative fasting time of 6 h for6’ – A minimum pre-operative fasting time of 6 h for
food (solids, milk and milk-containing drinks).food (solids, milk and milk-containing drinks).
 ChildrenChildren
 Pre-operative fasting in children undergoing electivePre-operative fasting in children undergoing elective
surgery –‘the 2-4-6 rule’:surgery –‘the 2-4-6 rule’:
 • ‘• ‘2’ – Intake of water and other clear fluid up to 2 h2’ – Intake of water and other clear fluid up to 2 h
before induction of anesthesia.before induction of anesthesia.
 • ‘• ‘4’ – Breast milk up to 4 h before.4’ – Breast milk up to 4 h before.
 • ‘• ‘6’ – Formula milk, cow’s milk or solids up to 6 h before.6’ – Formula milk, cow’s milk or solids up to 6 h before.

57. CONSENTCONSENT
 The anesthetist should explain the nature of anesthesia andThe anesthetist should explain the nature of anesthesia and
its attendant risks, to the patient in clear and simple termsits attendant risks, to the patient in clear and simple terms

58. intRaopeRative pHaSeintRaopeRative pHaSe

59. •““tRiaD of geneRaL aneStHeSia”tRiaD of geneRaL aneStHeSia”
 Need for unconsciousnessNeed for unconsciousness
 Need for analgesia(Pain relief)Need for analgesia(Pain relief)
 Need for muscle relaxationNeed for muscle relaxation
 Intraoperatively ,the anesthetist should provide generalIntraoperatively ,the anesthetist should provide general
anesthetic triad while ensuring maintenance of tissueanesthetic triad while ensuring maintenance of tissue
perfusion & oxygenationperfusion & oxygenation

60. geneRaL anaeStHetic agentSgeneRaL anaeStHetic agentS
 cLaSSification:cLaSSification:
Inhalational agents:
Gas Liquid
Nitrous oxide Ether
Halothane
Enflurane
Isoflurane
Desflurane
Savoflurane
Intravenous agentsIntravenous agents
1.1. Inducing agents :Inducing agents :
 Thiopental sodiumThiopental sodium
 Methohexitone sodiumMethohexitone sodium
 PropofolPropofol
 EtomidateEtomidate
2.2. Slower acting agents :Slower acting agents :
 BenzodiazepinesBenzodiazepines
 DiazepamDiazepam
 LorazepamLorazepam
 MidazolamMidazolam
3.3. Dissociaitive anaesthesiaDissociaitive anaesthesia
 KetamineKetamine
4.4.Opiod analgesiaOpiod analgesia
FentanylFentanyl

61.  General anesthetic agents are drugs which produce reversibleGeneral anesthetic agents are drugs which produce reversible
loss of all sensations and consciousnessloss of all sensations and consciousness
 Induction of anesthesia :Induction of anesthesia :
 Induction agents are those drugs used to start anesthesiaInduction agents are those drugs used to start anesthesia
 Consciousness is regained as these drugs are redistributed fromConsciousness is regained as these drugs are redistributed from
brain to tissuesbrain to tissues..
 Inducing agents may beInducing agents may be
•Intravenous agents
•Inhalation agents

62. intRavenoUS agentSintRavenoUS agentS
1.Sodium thiopentone:1.Sodium thiopentone:
 Water soluble barbiturate.Water soluble barbiturate.
 Available in 0.5% (500mg in 20 ml )Available in 0.5% (500mg in 20 ml )
 Painless on injectionPainless on injection
 Induction -Dose 2.7 mg/kgInduction -Dose 2.7 mg/kg
 Consciousness returns after 4-10 minConsciousness returns after 4-10 min
2.Propofol:2.Propofol:
 Phenolic derivative, not water soluble.Phenolic derivative, not water soluble.
 Prepared as emulsion 1% solution (200 mg in 20 ml)Prepared as emulsion 1% solution (200 mg in 20 ml)
 Gives pain /burning sensation on injectionGives pain /burning sensation on injection

63.  Induction –Dose 1.5-2.5 mg /kgInduction –Dose 1.5-2.5 mg /kg
 Consciousness' returns after 4- 7 minConsciousness' returns after 4- 7 min
3.ketamine:3.ketamine:
 Phencyclidine derivative, water solublePhencyclidine derivative, water soluble
 Available in 3 different concentrationsAvailable in 3 different concentrations
 10mg/ml, 50mg/ml, 100mg/ml10mg/ml, 50mg/ml, 100mg/ml
 Can be given as both I.V and I.MCan be given as both I.V and I.M

64.  Induction –Dose I.V 1-2 mg/kgInduction –Dose I.V 1-2 mg/kg
I.M 5-10 mg/kgI.M 5-10 mg/kg
 It takes 8-10 min to lose consciousnessIt takes 8-10 min to lose consciousness
 Duration of action is variableDuration of action is variable
 4.Midazolam :4.Midazolam :
 It is a benzodiazepineIt is a benzodiazepine
 Occasionally used as inducing agentOccasionally used as inducing agent
 Of the I.V agents currently in use, only propofol is usedOf the I.V agents currently in use, only propofol is used
subsequently to maintain anesthesiasubsequently to maintain anesthesia

65. Maintenance of aneStHeSiaMaintenance of aneStHeSia
 Following induction anesthesia is most commonly maintainedFollowing induction anesthesia is most commonly maintained
by administration of a combination of nitrous oxide & anby administration of a combination of nitrous oxide & an
anesthetic vapour in oxygen .anesthetic vapour in oxygen .
 Nitrous oxide :Nitrous oxide :
 Available in cylinders colored French blueAvailable in cylinders colored French blue
 Only inorganic gas used for anesthesiaOnly inorganic gas used for anesthesia
 Color less, sweet smelling, non irritant gasColor less, sweet smelling, non irritant gas
 Anesthesia – good analgesic but poor anesthetic agentAnesthesia – good analgesic but poor anesthetic agent
 Maximum safe concentration is 70% & 30% oxygenMaximum safe concentration is 70% & 30% oxygen

66. nitRoUS oxiDe cyLinDeRnitRoUS oxiDe cyLinDeR

67.  At the end of anesthesia there is rapid excretion of nitrousAt the end of anesthesia there is rapid excretion of nitrous
oxide into the alveoli diluting any remaining oxygenoxide into the alveoli diluting any remaining oxygen
present ,produces a transient hypoxia called diffusionpresent ,produces a transient hypoxia called diffusion
hypoxiahypoxia
 Also called fink effectAlso called fink effect
WHat iS fink effect?WHat iS fink effect?

68.  Diffusion hypoxiaDiffusion hypoxia Diffusion hypoxiaDiffusion hypoxia
O2
N2
N2O
PULMONARY
CAPILLARY
N2O

69.  Halothane :Halothane :
 Colorless, volatile, pleasant odour inhalation agent.Colorless, volatile, pleasant odour inhalation agent.
 AnesthesiaAnesthesia – very potent anesthetic agent– very potent anesthetic agent
 Administered via a calibrated vaporizer .Administered via a calibrated vaporizer .
 Induction can be achieved with 2- 4%Induction can be achieved with 2- 4%
 Maintenance with 0.5-1.5% inspired concentration whenMaintenance with 0.5-1.5% inspired concentration when
administered with 70% N2O +30% O2administered with 70% N2O +30% O2

70.  Isoflurane:Isoflurane:
 Colorless liquid, non inflammable and pungent smelling.Colorless liquid, non inflammable and pungent smelling.
 Anesthesia -Anesthesia -5% is required for induction5% is required for induction
 1-1.5% for maintenance1-1.5% for maintenance

71.  Sevoflurane :Sevoflurane :
 Pleasant smell , colorless liquid ,non inflammablePleasant smell , colorless liquid ,non inflammable
 Relatively weak anesthetic agent but good muscle relaxant.Relatively weak anesthetic agent but good muscle relaxant.
 The agent of choice forThe agent of choice for pediatric anesthesia.pediatric anesthesia.

72.  Propofol:Propofol:
 Intravenous infusing agentIntravenous infusing agent
 A typical infusion regimen in conjunction with oxygenA typical infusion regimen in conjunction with oxygen
enriched air, intravenous analgesic would beenriched air, intravenous analgesic would be
 10mg/kg/hr –For first 10 mins10mg/kg/hr –For first 10 mins
 8mg/kg/hr –For next 10 mins8mg/kg/hr –For next 10 mins
 6mg/kg/hr –For the duration of surgery6mg/kg/hr –For the duration of surgery

73.  Ether:Ether:
 AnesthesiaAnesthesia –– 15-25% (induction)15-25% (induction)
3-5% (maintenance)3-5% (maintenance)
10-12% (muscle relaxation)10-12% (muscle relaxation)
 Only inhalational agent that stimulates respirationOnly inhalational agent that stimulates respiration
 Because of its inflammable properties rarely used now a daysBecause of its inflammable properties rarely used now a days

74. Muscle relaxation duringMuscle relaxation during
anesthesiaanesthesia
 Used to facilitate tracheal intubationUsed to facilitate tracheal intubation
 Required to facilitate surgery & intermittent positive pressureRequired to facilitate surgery & intermittent positive pressure
ventilation(during maintenance period)ventilation(during maintenance period)
 Muscle relaxants may beMuscle relaxants may be
Depolarizing
Nondepolarizing

75. depolarizing agentsdepolarizing agents
 ScolineScoline::
 Mimics the action of acetylcholineMimics the action of acetylcholine
 Produces depolarization followed by uncoordinated muscleProduces depolarization followed by uncoordinated muscle
contractioncontraction
 Depolarization persists for several minutes there by preventsDepolarization persists for several minutes there by prevents
further muscle activity.further muscle activity.
 Available in 2ml ampoules(50mg/ml)Available in 2ml ampoules(50mg/ml)

76.  Dosage: can be given as I.V/I.M /subcutaneouslyDosage: can be given as I.V/I.M /subcutaneously
 1.5mg/kg body wt1.5mg/kg body wt
 Results in profound relaxation in 40-60 seconmdsResults in profound relaxation in 40-60 seconmds
 Lasts for 4-6 minsLasts for 4-6 mins
Depolarizing agents does not require reversal agents

77. nondepolarizing agentsnondepolarizing agents
 Competes with acetylcholine & blocks its access toCompetes with acetylcholine & blocks its access to
postsynaptic receptor sites on musclepostsynaptic receptor sites on muscle
 Can be used in 2 waysCan be used in 2 ways
• Following scoline in order to maintain relaxation duringFollowing scoline in order to maintain relaxation during
surgery orsurgery or
• As a sole agent to provide relaxation for tracheal intubationAs a sole agent to provide relaxation for tracheal intubation
Nondepolarizing agents require reversal agents

78.  Tubocurarine:Tubocurarine:
 Long acting relaxantLong acting relaxant
 Available in 1.5 ml ampoules (10mg/ml)Available in 1.5 ml ampoules (10mg/ml)
 Dosage: initial dose 0.5 mg/kg (takes 3 min for relaxation )Dosage: initial dose 0.5 mg/kg (takes 3 min for relaxation )
 Duration of action 30-40 minDuration of action 30-40 min
 Supplementary dose 0.15 mg/kg can be given to extend theSupplementary dose 0.15 mg/kg can be given to extend the
durationduration

79.  Atracurium:Atracurium:
 First modern generation muscle relaxantFirst modern generation muscle relaxant
 Intermediate actingIntermediate acting
 Dose: 0.5 mg/kg( takes 1.5-2 min)Dose: 0.5 mg/kg( takes 1.5-2 min)
 Duration of action is 20-25 minDuration of action is 20-25 min
 For prolonged procedures 0.5 mg /kg/hr (infusion)For prolonged procedures 0.5 mg /kg/hr (infusion)

80.  Vecuronium :Vecuronium :
 Supplied as powder( 10mg) ,reconstituted with 5 ml sterileSupplied as powder( 10mg) ,reconstituted with 5 ml sterile
water -2mg/mlwater -2mg/ml
 Dose: 0.1 mg/kgDose: 0.1 mg/kg
 Takes 1.5 -2 min for onset of actionTakes 1.5 -2 min for onset of action
 Duration of action 15-20 minDuration of action 15-20 min
 Duration can be extended by 0.15-0.2 mg/kgDuration can be extended by 0.15-0.2 mg/kg
 For prolonged procedures 50-80micro grm/kg/hr(infusion)For prolonged procedures 50-80micro grm/kg/hr(infusion)

81.  Mivacurium:Mivacurium:
 Available in 2mg/mlAvailable in 2mg/ml
 Dose: 0.15mg/kg (allows intubation after 2 mins)Dose: 0.15mg/kg (allows intubation after 2 mins)
 Duration of action is 10-15 minDuration of action is 10-15 min

82. reversal of anesthesiareversal of anesthesia
 The only component that is truly reversible at the conclusionThe only component that is truly reversible at the conclusion
of G.A is the effect of the non depolarizing muscle relaxantof G.A is the effect of the non depolarizing muscle relaxant
 Non depolarizing muscle relaxant is reversed by anti cholineNon depolarizing muscle relaxant is reversed by anti choline
esterase drugs .esterase drugs .
e.g. Neostigmine sulphate (0.05- 0.07 mg/ kg)e.g. Neostigmine sulphate (0.05- 0.07 mg/ kg)
 Usually administered with either atropine (1.2mg) orUsually administered with either atropine (1.2mg) or
glycopyrrolate(0.5mg)glycopyrrolate(0.5mg)

83. need for g.a in Maxillofacial surgerYneed for g.a in Maxillofacial surgerY
 Major surgical procedures.Major surgical procedures.
 Inability to tolerate dental treatment under L.AInability to tolerate dental treatment under L.A
 Failure of previous attempt to treat under L.AFailure of previous attempt to treat under L.A
 Patients with medical disability which make it impossiblePatients with medical disability which make it impossible
to sit stillto sit still
 Acute infection in which L.A may not be effectiveAcute infection in which L.A may not be effective
 True allergy to L.ATrue allergy to L.A

84. advantages of g.aadvantages of g.a
 Patient cooperation not absolutely essentialPatient cooperation not absolutely essential
 UnconsciousnessUnconsciousness
 AmnesiaAmnesia
 Rapid onset of actionRapid onset of action
 Titration possibleTitration possible
 The patient does not respond to painThe patient does not respond to pain
 Unlimited operating timeUnlimited operating time

85. disadvantages of g.adisadvantages of g.a
 Loss of protective reflexesLoss of protective reflexes
 Depression of vital signsDepression of vital signs
 Advanced training is requiredAdvanced training is required
 Additional personnel is requiredAdditional personnel is required
 Special equipment / setting is necessary.Special equipment / setting is necessary.
 Need for recovery roomNeed for recovery room
 Greater risk of intraoperative complicationsGreater risk of intraoperative complications
 Post anesthetic complicationsPost anesthetic complications
 More extensive preoperative evaluation, including lab workMore extensive preoperative evaluation, including lab work
is necessary.is necessary.

86.  Skin preparation – ‘prepping’ and draping:Skin preparation – ‘prepping’ and draping:
 To reduce the microbial count on the patient’s skin , toTo reduce the microbial count on the patient’s skin , to
inhibit microbial regrowth and contamination of the woundinhibit microbial regrowth and contamination of the wound
itself during surgery.itself during surgery.
 ‘‘Pre-prep’Pre-prep’
 The skin of the patient must be prepared before formalThe skin of the patient must be prepared before formal
surgical skin preparation to remove soil and debrissurgical skin preparation to remove soil and debris..
 For patients undergoing elective surgery, a shower on theFor patients undergoing elective surgery, a shower on the
day of surgery with a soapy disinfectant.day of surgery with a soapy disinfectant.
 Skin preparation solution – ‘prep’Skin preparation solution – ‘prep’

87. Method of preparing the skin

88.  Draping of the operative area:Draping of the operative area:
 Covering with sterile barrier material, ‘drapes’, the areaCovering with sterile barrier material, ‘drapes’, the area
immediately surrounding the operative site.immediately surrounding the operative site.
 To create and maintain a protective zone of asepsis, called aTo create and maintain a protective zone of asepsis, called a
‘sterile field’.‘sterile field’.

89. intraoperative coMplicationsintraoperative coMplications
 Due to anesthesia:Due to anesthesia: Anesthetic complications depend on theAnesthetic complications depend on the
mode (General or Local) and types of anesthetic agent usedmode (General or Local) and types of anesthetic agent used
(anesthetic agent toxicity(anesthetic agent toxicity).).
 Most common complications of G.A:Most common complications of G.A:
 Direct trauma to the mouthDirect trauma to the mouth
 Slow recovery from anesthesia due to drug interactions orSlow recovery from anesthesia due to drug interactions or
inappropriate choice of drug dosage.inappropriate choice of drug dosage.
 Hypothermia due to long operations with extensive fluidHypothermia due to long operations with extensive fluid
replacement/cold blood transfusion.replacement/cold blood transfusion.
 Allergic reaction to anesthetic agentAllergic reaction to anesthetic agent

90. Complications during intubationComplications during intubation::
 TTrauma to lip, tongue or teethrauma to lip, tongue or teeth
 HHypertension and tachycardia or arrhythmiaypertension and tachycardia or arrhythmia
 PPulmonary aspirationulmonary aspiration
 LLaryngospasmaryngospasm
 BBronchospasmronchospasm
 LLaryngeal edemaaryngeal edema
 SSpinal cord trauma in cervical spine injurypinal cord trauma in cervical spine injury

91.  During extrubation:During extrubation:
 LaryngospasmLaryngospasm
 Pulmonary aspirationPulmonary aspiration
 Edema of upper airwayEdema of upper airway
 During surgery:During surgery:
 Bleeding.Bleeding.
 M.IM.I
 AspirationAspiration
 Respiratory depressionRespiratory depression
 HypoxiaHypoxia
 HypothermiaHypothermia
 Hypotension.Hypotension.
 Raised B.PRaised B.P
 Cardiac arrest.Cardiac arrest.

92.  Bleeding:Bleeding: Most common complication in OMFSMost common complication in OMFS
 C/F: Increased pulse rate, low B.P, inc pallor, restlessness,C/F: Increased pulse rate, low B.P, inc pallor, restlessness,
deep sighing respiration, cold and calmmy extremetiesdeep sighing respiration, cold and calmmy extremeties
 Measurement of blood loss in theater is byMeasurement of blood loss in theater is by
1.1. Weighing of swabs( best method)Weighing of swabs( best method)
2.2. Measurement of swellings in closed fractureMeasurement of swellings in closed fracture
3.3. Measurement of blood clot.(blood clot of the clenched fistMeasurement of blood clot.(blood clot of the clenched fist
=500 ml )=500 ml )

93.  Blood Loss in Orthognathic Surgery: A Systematic ReviewBlood Loss in Orthognathic Surgery: A Systematic Review
 Official journal of the american association of oral and maxillofacialOfficial journal of the american association of oral and maxillofacial
surgeons · (dec 2010)surgeons · (dec 2010)
 A systematic review of the data regarding intraoperativeA systematic review of the data regarding intraoperative
blood loss during orthognathic surgical interventions,blood loss during orthognathic surgical interventions,
including Le Fort I osteotomy, mandibular ramus osteotomy,including Le Fort I osteotomy, mandibular ramus osteotomy,
and both combinedand both combined
 RESUILTS: The mean intraoperative bleeding volume wasRESUILTS: The mean intraoperative bleeding volume was
436.11 mL, and mean surgery duration was 196.9 minutes.436.11 mL, and mean surgery duration was 196.9 minutes.

94.  Predictors of intra-operative blood loss and blood transfusionPredictors of intra-operative blood loss and blood transfusion
in orthognathic surgery: a retrospective cohort study in 92in orthognathic surgery: a retrospective cohort study in 92
patients.patients.
Al -Sebaei Patient Safety in Surgery 2014, 8:41Al -Sebaei Patient Safety in Surgery 2014, 8:41
 The objectives of this study ,to evaluate the predictors ofThe objectives of this study ,to evaluate the predictors of
intra-operative blood loss in patients undergoingintra-operative blood loss in patients undergoing
orthognathic procedures and the transfusion rates.orthognathic procedures and the transfusion rates.
 Materials and methodsMaterials and methods: This retrospective study included 92: This retrospective study included 92
patients who underwent the following four types ofpatients who underwent the following four types of
orthognathic procedures: Group 1, bimaxillary; Group 2,orthognathic procedures: Group 1, bimaxillary; Group 2,
bimaxillary with bone grafts; Group 3, LeFort I osteotomies;bimaxillary with bone grafts; Group 3, LeFort I osteotomies;
and Group 4, LeFort I osteotomies with bone graftsand Group 4, LeFort I osteotomies with bone grafts

95. ..
 Results: The mean blood loss for all groups was 650 ±Results: The mean blood loss for all groups was 650 ±
397.8 mL (p < 0.001, r =0.332).397.8 mL (p < 0.001, r =0.332).
 Eighteen of the 92 patients (19.5%) received bloodEighteen of the 92 patients (19.5%) received blood
transfusions.transfusions.
 Conclusion: The only predictor of intra-operative bloodConclusion: The only predictor of intra-operative blood
loss was operative time.loss was operative time.

96.  Intra-operative blood loss and operating time inIntra-operative blood loss and operating time in
orthognathic surgery using induced hypotensive generalorthognathic surgery using induced hypotensive general
anesthesia: prospective studyanesthesia: prospective study (CNF Yu, TK Chow et.al )(CNF Yu, TK Chow et.al )
HKMJ Vol 6 No 3 September 2000HKMJ Vol 6 No 3 September 2000
 32 patients ( 1 yr study)32 patients ( 1 yr study)
 Most patients (72.4%) needed double-jaw surgery(MEBLMost patients (72.4%) needed double-jaw surgery(MEBL
617.6 Ml)617.6 Ml)
 The blood loss during simple Le Fort I osteotomies was aboutThe blood loss during simple Le Fort I osteotomies was about
half that of multiple segmentalised osteotomies.half that of multiple segmentalised osteotomies.
 For mandibular ramus osteotomies, the mean blood loss andFor mandibular ramus osteotomies, the mean blood loss and
operating time were approximately 280 mL and 2 hours,operating time were approximately 280 mL and 2 hours,
respectivelyrespectively

97.  For anterior mandibular osteotomies, the correspondingFor anterior mandibular osteotomies, the corresponding
values were 171.3 mL and 1 hour 13 minutes.values were 171.3 mL and 1 hour 13 minutes.

98. discharge froM recoverYdischarge froM recoverY

99.  Patient must be able to maintain their airway unassistedPatient must be able to maintain their airway unassisted
 Protective reflexes should be intactProtective reflexes should be intact
 RS & CVS indices – within anticipated rangeRS & CVS indices – within anticipated range
 Recovery from neuro muscular blockageRecovery from neuro muscular blockage
 Head lift off pillow for at least 5 secHead lift off pillow for at least 5 sec
 Protrusion of tongueProtrusion of tongue

100. postoperative phasepostoperative phase
 Postoperative care involves assessment, diagnosis, planning,Postoperative care involves assessment, diagnosis, planning,
intervention, and outcome evaluation.intervention, and outcome evaluation.
 The extent of postoperative care required depends on theThe extent of postoperative care required depends on the
individual's pre-surgical health status, type of surgery and ofindividual's pre-surgical health status, type of surgery and of
the duration of the surgery.the duration of the surgery.
 Vital signs should be monitoredVital signs should be monitored
Every 15 minutes for first hourEvery 15 minutes for first hour
Every half an hour until stableEvery half an hour until stable
Finally every 4 hourlyFinally every 4 hourly

101. Maintain intaKe and outputMaintain intaKe and output

102.  Position of the patient:Position of the patient: Elevation of the head is mostElevation of the head is most
comfortable for the patientcomfortable for the patient

103. coMplicationscoMplications
An anaesthetic complication may be defined as
deviation from the normally expected physiological pattern
during or after the administration of anaesthesia.

104. postoperative coMplicationspostoperative coMplications
 Complications associated with introduction ofComplications associated with introduction of
infusioninfusion
 Specific post operative complicationsSpecific post operative complications
 General complicationsGeneral complications
 Wound complicationsWound complications
 Respiratory complicationsRespiratory complications
 Cardiovascular complicationsCardiovascular complications
 Gastrointestinal complicationsGastrointestinal complications
 Urinary complicationsUrinary complications
 Neurological complicationsNeurological complications
 Postoperative feverPostoperative fever

105.  Complications associated with the introduction ofComplications associated with the introduction of
infusion:infusion:
 Air embolismAir embolism
 CauseCause: when more than 15 ml of air is accidentally: when more than 15 ml of air is accidentally
introduced during or after insertion of a venous catheter.introduced during or after insertion of a venous catheter.
 PREVENTION: By running fluids through the giving setsPREVENTION: By running fluids through the giving sets
before connecting to the patient.before connecting to the patient.
 Decrease B.PDecrease B.P
 Increase pulse rateIncrease pulse rate
 Distension of JVPDistension of JVP

106.  Phlebitis:Phlebitis:
 A needle or catheter inserted into a vein will eventually resultA needle or catheter inserted into a vein will eventually result
in inflammation around the area (phlebitis).in inflammation around the area (phlebitis).
 Depends onDepends on
 Phlebitis may cause postoperative pyrexia.Phlebitis may cause postoperative pyrexia.
 Signs:Signs:
 Duration of insertion ofDuration of insertion of
catheterscatheters
 Nature of fluidsNature of fluids
 Bacterial contaminationBacterial contamination
 Evidence of indurationsEvidence of indurations
 EdemaEdema
 TendernessTenderness

107.  Management:Management:
 Remove the cannulae if signs are presentRemove the cannulae if signs are present
 Should be changed at 72 hrlyShould be changed at 72 hrly
 Specific postoperative complicationsSpecific postoperative complications
 Respiratory complications :Respiratory complications :
 Airway obstructionAirway obstruction::
 May be partial/complete(increased respiratory effort)May be partial/complete(increased respiratory effort)
 causescauses: Foreign body, excessive mucus, or tongue falling: Foreign body, excessive mucus, or tongue falling
back into pharynxback into pharynx

108.  Signs and symptomsSigns and symptoms::
 DyspnoeaDyspnoea
 TachypneaTachypnea
 Chest retractionChest retraction
 CyanosisCyanosis
 Decreased saturation of oxygenDecreased saturation of oxygen
 ManagementManagement::
 Head position(Neck extended ,jaw pulled forward)Head position(Neck extended ,jaw pulled forward)
 Suctioning of oral cavity and pharynxSuctioning of oral cavity and pharynx
 Artificial airwayArtificial airway
 Oxygen supplementationOxygen supplementation
 Endotracheal intubationEndotracheal intubation

109. Atelectasis :Atelectasis :
 postoperative atelectasispostoperative atelectasis constitutes around 90% of allconstitutes around 90% of all
surgical pulmonary complications.surgical pulmonary complications.
 The lung tissue collapses due to the depressing effects of theThe lung tissue collapses due to the depressing effects of the
anesthetic medication.anesthetic medication.
 Usually occurs within 48 hours after the surgery isUsually occurs within 48 hours after the surgery is
completed.completed.
 Defined as the collapse or closure of the lung resulting
in reduced or absent gas exchange.
 Produced by inadequate pulmonary ventilation

110.  SIGNS AND SYMPTOMSSIGNS AND SYMPTOMS::
 Shallow breathingShallow breathing
 FeverFever
 Increase in heart rateIncrease in heart rate
 Pain in the chestPain in the chest
 Coughing, but not a prominent coughCoughing, but not a prominent cough
 DIAGNOSISDIAGNOSIS- Decreased breath sounds at the lung base- Decreased breath sounds at the lung base

111.  TREATMENT-TREATMENT-
 The treatment for postoperative Atelectasis usually involvesThe treatment for postoperative Atelectasis usually involves
physiotherapyphysiotherapy
 Reexpansion of the lung by advising deep breathing andReexpansion of the lung by advising deep breathing and
coughingcoughing
 Bronchodilator like solubutomal for bronchospasm.Bronchodilator like solubutomal for bronchospasm.
 Antibiotics at the time of infectionAntibiotics at the time of infection

112. ASPIRATION PNEUMONIAASPIRATION PNEUMONIA
 Cause:Cause:
 Aspiration of gastric contentsAspiration of gastric contents
 Aspiration of particulate matter, blood or secretionsAspiration of particulate matter, blood or secretions
 Predisposing factors:Predisposing factors:
 Full stomachFull stomach
 Oesophageal motility disordersOesophageal motility disorders
 Bowel obstructionBowel obstruction
 Drug overdoseDrug overdose

113. MANAGEMENTMANAGEMENT
 Trendlenburg positionTrendlenburg position
 SuctioningSuctioning
 BronchoscopyBronchoscopy
 Positive pressure ventilationPositive pressure ventilation
 Bronchodilators like aminophyllineBronchodilators like aminophylline
 Antibiotic therapyAntibiotic therapy
 I.V corticosteroidsI.V corticosteroids

114.  Cardiovascular complications:Cardiovascular complications:
 Hypotension:Hypotension:
 Most common cause is hypovolemia (bleeding or insufficientMost common cause is hypovolemia (bleeding or insufficient
fluid replacement)fluid replacement)
 Drugs like muscle relaxants & narcoticsDrugs like muscle relaxants & narcotics
 ManagementManagement::
 Increase in the fluid input with administration of high flowIncrease in the fluid input with administration of high flow
oxygen.oxygen.
 The patient should also be tilted head-down to maintainThe patient should also be tilted head-down to maintain
cerebral perfusioncerebral perfusion
 I.V. EPHEDRINE 5-10 mgI.V. EPHEDRINE 5-10 mg
 ..

115.  Hypertension:Hypertension:
 Causes:Causes:
 Increase in pain and anxietyIncrease in pain and anxiety
 Hypoxia or hypercapneaHypoxia or hypercapnea
 Urinary retentionUrinary retention
 Positive fluid balancePositive fluid balance..
 ManagementManagement::
 Treatment of suspected causeTreatment of suspected cause
 Settles with appropriate analgesicsSettles with appropriate analgesics
 Antihypertensive therapyAntihypertensive therapy
(ca channel blockers)(ca channel blockers)

116.  Tachycardia:Tachycardia:
 Causes:Causes:
 Management:Management:
 Treat the underlying cause.Treat the underlying cause.
 I.V.propranolol 1.5mgI.V.propranolol 1.5mg
 HypovolemiaHypovolemia
 HypoxiaHypoxia
 PainPain
 FeverFever

117.  Deep vein thrombosisDeep vein thrombosis::
 Risk factors for DVTRisk factors for DVT
 Signs:Signs:
 Calf pain , swelling, warmth, redness & engorged veinsCalf pain , swelling, warmth, redness & engorged veins
 Prevention:Prevention:
 Age > 60 yrsAge > 60 yrs
 Prolonged immobilizationProlonged immobilization
 TraumaTrauma
 Obesity oral contraceptivesObesity oral contraceptives
 Recent surgeries(pelvic/lowerRecent surgeries(pelvic/lower
limb)limb)

118.  Management:Management:
 I.V heparin followed by long term warfarin.I.V heparin followed by long term warfarin.
 Untreated DVT may result in pulmonary embolism whichUntreated DVT may result in pulmonary embolism which
may be fatal.may be fatal.

119.  Gastrointestinal complications:Gastrointestinal complications:
 Postoperative nausea and vomiting:Postoperative nausea and vomiting:
 predisposing factors for nausea and vomiting in postoperativepredisposing factors for nausea and vomiting in postoperative
patients:patients:
 Patient has recently eaten.Patient has recently eaten.
 Poorly controlled painPoorly controlled pain
 Use of opioids.Use of opioids.
 Female sex & young adultsFemale sex & young adults
 History of preoperative vomitingHistory of preoperative vomiting
 History of motion sickness or migrane.History of motion sickness or migrane.

120. complications :complications :
 Aspiration pneumoniaAspiration pneumonia
 DehydrationDehydration
 Electrolyte imbalanceElectrolyte imbalance
 Esophageal ruptureEsophageal rupture
 MANAGEMENTMANAGEMENT::
 NPO 6 hours before procedureNPO 6 hours before procedure
( normal gastric emptying time is 30-90 minutes & it is( normal gastric emptying time is 30-90 minutes & it is
increased during times of stress )increased during times of stress )
 Decrease apprehension, pain and use of opiatesDecrease apprehension, pain and use of opiates
 Trendelenburg position(apirate vomitus)Trendelenburg position(apirate vomitus)
 AntiemeticsAntiemetics

122.  Urinary complications:Urinary complications:
 Urine output (oliguria/anuria)Urine output (oliguria/anuria)
 Urine output less than the minimum obligatory volume (0.5Urine output less than the minimum obligatory volume (0.5
ml kg–1h–1).ml kg–1h–1).
 Commonest cause is reduced renal perfusion resulting fromCommonest cause is reduced renal perfusion resulting from
perioperative hypotension or inadequate fluid replacementperioperative hypotension or inadequate fluid replacement
 . If untreated, acute renal failure may develop.. If untreated, acute renal failure may develop.
 To ensure that fluid management is adequateTo ensure that fluid management is adequate
 Daily input/output charting should be maintained.Daily input/output charting should be maintained.
 The urine output should be measured on an hourly basis afterThe urine output should be measured on an hourly basis after
major surgery tomajor surgery to

123.  The serum levels of urea and creatinine should be measuredThe serum levels of urea and creatinine should be measured
daily until the patient is fully recovereddaily until the patient is fully recovered
 If a postoperative patient develops a drop in the urineIf a postoperative patient develops a drop in the urine
outputoutput
(it is sensible to first check whether the catheter is blocked.)(it is sensible to first check whether the catheter is blocked.)
 If hypovolaemia is suspected, a fluid challenge of 250 mlIf hypovolaemia is suspected, a fluid challenge of 250 ml
of intravenous fluid should be given over 1 hour.of intravenous fluid should be given over 1 hour.

124.  Urinary retention:Urinary retention:
 This is frequently seen in postoperative patients, particularlyThis is frequently seen in postoperative patients, particularly
men.men.
 The inability to void after surgery(secondary toThe inability to void after surgery(secondary to
anesthesia,drugs)anesthesia,drugs)
 Pain in acute urinary retention.Pain in acute urinary retention.
 Diagnosed by palpation (thin persons),or dullness onDiagnosed by palpation (thin persons),or dullness on
percussion above symphysis pubis.percussion above symphysis pubis.
 May be confirmed by USG.May be confirmed by USG.
 Management:Management:
 A dose omnopon (to relieve anxiety ).A dose omnopon (to relieve anxiety ).
 Hot and cold application to suprapubic region.Hot and cold application to suprapubic region.
 CatheterisationCatheterisation

126.  May respond to alpha blockers and 5- alpha reductaseMay respond to alpha blockers and 5- alpha reductase
inhibitor therapy,diuretics.inhibitor therapy,diuretics.
 If all methods fails one of the following methods are adoptedIf all methods fails one of the following methods are adopted
 Suprapubic punctureSuprapubic puncture
 Suprapubic cystotomySuprapubic cystotomy
 Immediate prostectomy(benignImmediate prostectomy(benign
enlargement )enlargement )
 Urethral instrumentationUrethral instrumentation

127.  Urinary infectionUrinary infection::
 one of the most commonly acquired infections in theone of the most commonly acquired infections in the
postoperative periodpostoperative period
 RISK FACTORS:RISK FACTORS:
 Symptoms:Symptoms:
 Diagnosis :Dipsticking the urine &culture samplingDiagnosis :Dipsticking the urine &culture sampling
 ImmunocompromisedImmunocompromised
 DiabeticDiabetic
 Pre-existing UTPre-existing UT
contaminationcontamination
 Presence of cathetersPresence of catheters
 DysuriaDysuria
 Mild pyrexiaMild pyrexia

128.  TREATMENT:TREATMENT:
 Relevant antibioticsRelevant antibiotics
 Adequate drainage of the bladder.Adequate drainage of the bladder.
 Adequate fluid managementAdequate fluid management

129.  Neurological complications:Neurological complications:
 Most common neurological complications are convulsions andMost common neurological complications are convulsions and
emergence deliriumemergence delirium
 Probably due to hypoxia and hypercapnea.Probably due to hypoxia and hypercapnea.
 Emergence delirium is a state of excitement during recoveryEmergence delirium is a state of excitement during recovery
from anesthesiafrom anesthesia
 Requires sedation with tranquilizer or a narcotic (I.V)Requires sedation with tranquilizer or a narcotic (I.V)

130.  General complication:General complication:
 Postoperative fever:Postoperative fever: 40% of patients develop pyrexia after40% of patients develop pyrexia after
major surgerymajor surgery
 80% of cases no particular cause is found.80% of cases no particular cause is found.
 The inflammatory response to surgical trauma may manifestThe inflammatory response to surgical trauma may manifest
as temperature.as temperature.

131.  The causes of raised temperature postoperativelyThe causes of raised temperature postoperatively
include:include:
 days 2–5: atelectasis of the lung;days 2–5: atelectasis of the lung;
 days 3–5: superficial and deep wound infection;days 3–5: superficial and deep wound infection;
 day 5: chest infection including viral respiratory tractday 5: chest infection including viral respiratory tract
infection, urinary tract infection and thrombophlebitis;infection, urinary tract infection and thrombophlebitis;
 >5 days: wound infection, anastomotic leakage,>5 days: wound infection, anastomotic leakage,
intracavitary collections and abscesses;intracavitary collections and abscesses;
 ••..

132.  Infected intravenous cannula sites, DVTs, transfusionInfected intravenous cannula sites, DVTs, transfusion
reactions, wound haematomas, atelectasis and drugreactions, wound haematomas, atelectasis and drug
reactions.reactions.
 Persistent pyrexia need a thorough review.Persistent pyrexia need a thorough review.
 Relevant investigations include full blood count, urineRelevant investigations include full blood count, urine
culture if urinary tract infection is suspected, sputumculture if urinary tract infection is suspected, sputum
microscopy, chest radiography if indicated and bloodmicroscopy, chest radiography if indicated and blood
culturescultures
 Empiric antibiotics if necessaryEmpiric antibiotics if necessary

133.  WOUND COMPLICATION:WOUND COMPLICATION:
 HematomasHematomas::
 It is a collection of blood in the wound due to inadequateIt is a collection of blood in the wound due to inadequate
haemostasis.haemostasis.
 Good media for bacteriaGood media for bacteria
 Manifested by pain and swellingManifested by pain and swelling
 Drains should be usedDrains should be used
 Seromas:Seromas:
It is collection of fluid other than pus or blood.It is collection of fluid other than pus or blood.
 No erythema or tenderness is seen.No erythema or tenderness is seen.
 Closed suction drain with pressure dressings.Closed suction drain with pressure dressings.

134.  Wound dehiscence:Wound dehiscence:
 This is the partial or completeThis is the partial or complete
disruption of any or all of thedisruption of any or all of the
layers in a wound.layers in a wound.
 Wound dehiscence mostWound dehiscence most
commonly occurs from the fifthcommonly occurs from the fifth
to the eight postoperative dayto the eight postoperative day
when the strength of the woundwhen the strength of the wound
is at its weakest.is at its weakest.
 Wound dehiscence usuallyWound dehiscence usually
presents with a serosanguinouspresents with a serosanguinous
discharge.discharge.

136.  ManagementManagement::
 Most patients will need to return to the O.T forMost patients will need to return to the O.T for
resuturing.resuturing.
 In some patients it may be appropriate to leave theIn some patients it may be appropriate to leave the
wound open and treat with dressings or vacuum-wound open and treat with dressings or vacuum-
assisted closure (VAC) pumpsassisted closure (VAC) pumps

137. FOllOw UPFOllOw UP
 To assume responsibility for the patient's after-care until all
possibility of post-OP complications is past.
 Long-term follow-up will benefit both the surgeon and his
patients.

138. CONClUSIONCONClUSION
 To reduce the patient’s surgical and anestheticTo reduce the patient’s surgical and anesthetic
perioperative morbidity or mortality,perioperative morbidity or mortality, and to return him toand to return him to
desirable functioning as quickly as possible good patientdesirable functioning as quickly as possible good patient
management is absolutely necessary .management is absolutely necessary .

139. REFERENCESREFERENCES
 Textbook of pharmacologyTextbook of pharmacology
by K. D. Tripathiby K. D. Tripathi
 Textbook of medicineTextbook of medicine
by Davidsonby Davidson
 Text book of oral and maxillofacial surgeryText book of oral and maxillofacial surgery
by SM Balajiby SM Balaji
 Baiely and Love short practice of surgeryBaiely and Love short practice of surgery
 Text book of suegery by DasText book of suegery by Das

140. Thank youThank you