1. General Surgery Mosul university- College of dentistry-oral & maxillofacial surgery department Dr. Ziad H. Delemi B.D.S, F.I.B.M.S (M.F.) Post-operative care and management

2. Mosul university- College of dentistry-oral & maxillofacial surgery department Phases І-Immediate post-anesthetic phase. ІІ-Intermediate phase. ІІІ-Convalescent (recovery) phase.

3. Mosul university- College of dentistry-oral & maxillofacial surgery department Immediate post-anesthetic phase 1- monitoring 2- respiratory care 3- cardiovascular system (CVS) care 4- renal & bladder care 5- drainage tubes 6- medication 7- special laboratory tests

4. Mosul university- College of dentistry-oral & maxillofacial surgery department 1- monitoring: Observation in recovery room until the patient is conscious & vital sings are stable done by the surgeon & anesthetist then order written on the case sheet & the nursing staff informed. vital signs ( BP, PR, RR, UOP ) recorded every 15-30 min. then 1 hrly on the chart. continuous ECG some times are needed

5. Mosul university- College of dentistry-oral & maxillofacial surgery department 2- respiratory care: Maintain open airway by:  Side position till gag reflex +ve.  Mechanical suction of the blood & mucus secretions.  Encourage breathing & cough.  Sitting as soon as possible.  Turn the patient from side to side every 15-30 min then hourly for first 8-12 hrs to prevent atelectasis & facilitate lung expansion.

6. Mosul university- College of dentistry-oral & maxillofacial surgery department 3- cardiovascular system (CVS): to prevent DVT active motion of the lower limb is encourage, in elderly patients we use elastic support stockings or bandages with continuous intra venous fluids (IVF) to prevent circulatory collapse.

7. Mosul university- College of dentistry-oral & maxillofacial surgery department 4- renal & bladder: Urinary out put (UOP) kept at least 30 ml /h, low UOP resulted from ↓BP, ↓ blood volume, renal failure, managed by IVF & diuretics. Urinary retention managed by tape water see or Foleys catheter or suprapubic cystostomy.

8. Mosul university- College of dentistry-oral & maxillofacial surgery department 5- drainage tubes: Drain : method to prevent fluid accumulation or drainage of pus or fluids or air from plural space. it introduced through a separate incision to ↓wound infections & must fixed to skin to prevent slipping into abdominal cavity Types: 1-soft lax (corrugate) 2-penrose 3-closed drain 4-sump drain

9. Mosul university- College of dentistry-oral & maxillofacial surgery department 6- medications: Antibiotic, analgesics, sedation, other drugs. 7- special laboratory tests: PCV & Hb if blood loss during surgery Blood chemistry & blood gases, portable X- ray in critical patient.

10. Mosul university- College of dentistry-oral & maxillofacial surgery department Intermediate phase 1- wound care. 2- drains. 3- respiratory care. 4- fluid & electrolytes. 5- gastrointestinal tract ( GIT ). 6- post operative pain.

11. Mosul university- College of dentistry-oral & maxillofacial surgery department 1- wound care:  Sterile dressing applied in the operative room  4 th post operative day dressing removed & wound inspected.  Sutures removed 5-15 days according to site.  If the healing is normal, patient allowed to bath in 7 th post operative day.  If wound contaminated it is best to leave the skin & subcutaneous tissue open then do delayed primary or secondary suturing.  Learn patient how to take care of the wound.

12. Mosul university- College of dentistry-oral & maxillofacial surgery department 2- drains: Quantity & quality of drained fluid should be noted. The drain must be removed if there is little or no drainage.

13. Mosul university- College of dentistry-oral & maxillofacial surgery department 3- respiratory care: The changes in the pulmonary function observed following general anesthesia & surgery are principley due to ↓ functional residual capacity & ↓ vital capacity with pulmonary edema.

14. Mosul university- College of dentistry-oral & maxillofacial surgery department 4- fluid & electrolytes :  Daily maintenance :for sensible & insensible loss in adult 1500-2500 cc so give 4-5 pints of glucose saline daily, K+ is not add 1 st 24 hrs.  Loss from the drain ( NG tube loss more than 500 ml/day so replace by G/S with K+.  Extraneed from systemic factor fever, burn.  Loss from 3 rd space sequestration from tissue edema or ileus.

15. Mosul university- College of dentistry-oral & maxillofacial surgery department 5- gastrointestinal tract (GIT): Post-operative paralytic ileus (bowel sound – ve) Peristalsis will return within 24 hrs so immediately put NG tube post-op. & connected to suction device with irrigation. Nothing by mouth till bowel sound +ve. Gastrostomy or jejunostomy also attached to succer.

16. Mosul university- College of dentistry-oral & maxillofacial surgery department 6- post operative pain: Post-operative pain cause: -↑ stress & this lead to delay recovery. -inability to cough & breath deeply will lead to retention of secretions atelectasis, pneumonia. -immobility lead to venous stasis, DVT, pulmonary embolisim.

17. Mosul university- College of dentistry-oral & maxillofacial surgery department Methods of relieving pain 1-Intermittent injection of analgesic drugs: a- morphine ( 3mg IV diluted in 3ml slowly) b- pethidine (75 mg IV infusion) c- pentazocine d- tramadol (100mg), or voltarin (75mg) IM 2- continuous IV infusion. 3- inhalational analgesia. 4- peripheral nerve block. 5- epidural (extradural) block. 6- oral analgesia ( NSAID, pethidine tab, codeine..)

18. Mosul university- College of dentistry-oral & maxillofacial surgery department Convalescent(recovery) phase Instruct the patient not to lift heavy weight or to cough heavily or to be constipated for at least 6 months post operative to prevent hernia. Prevent heavy fatty meals & gastric irritants in duodenal ulcer & acute cholycystitis. Prevent chronic constipation & prolonged standing in varicous veins & hemorrhoids.

19. Enumerate liver function tests (LFT) Mosul university- College of dentistry-oral & maxillofacial surgery department Quiz