OMFS 5 - Postoperative Management (Dr. Stephens)

True (must instruct verbally and give written instructions)

T/F: Once procedure complete patient and escort must be given proper instructions, such as...

- How to care for common postsurgical sequelae

- What they are likely to experience

- Why these phenomena occur

- How to manage and control typical postoperative situations

- Verbally/ Written or printed form on paper

- Include a telephone number at which the surgeon or covering on-call doctor can be reached

Post-operative care

These are all concerns with what?

- Bleeding

- Pain

- Diet

- Hygiene

- Edema

- Trismus

- Ecchymosis

- Keep fingers, tongue, toothbrush away from wound

- Ok to brush other areas

- Avoid vigorous rinsing for 24hrs

- - Warm salt water for next 4-5 days

- Resume normal brushing after ~5 days

What are some guidelines for healing?

Folded gauze over socket

What is the initial maneuver to control post-op bleeding?

30 min (and tell them to not to chew on the gauze - also patients should be told how to reapply a folded piece of gauze directly over the area of the extraction)

How long do you tell a patient to bite firmly on gauze after an extraction?

24 hours

How long is it normal for fresh extraction sites to ooze slightly after the extraction procedure?

True

T/F: A small amount of blood mixed with a large amount of saliva might appear to be a large amount of blood

Black tea bag

(NOT green tea or herbal tea)

What can patient's with continuous nuance bleeding place on the wound to control bleeding?

G) All of the above

Which of the following are post-op instructions for extractions?

A) Talking should be kept to a minimum for an hour

B) Tobacco smoke and nicotine interfere with wound healing

C) Avoid straws when drinking because this creates negative intraoral pressure

D) Should not spit during the first 12-24 hours after surgery

E) No strenuous exercises should be performed for the first 12 to 24 hours after extraction

F) Prolonged oozing, bright red bleeding, or large clots in the patient's mouth are indications for a return visit

G) All of the above

Controlling bleeding

What are these instructions for?

SOME SLIGHT OOZING OF BLOOD FROM THE WOUND IS NOT UNUSUAL. To minimize bleeding after an extraction, bite HARD and STEADILY on a rolled piece of gauze thus exerting pressure on the wound for a minimum of ½ hour and even as much as one hour. If bleeding should continue after removing the rolled gauze, wipe away the excess blood clot and place another piece of rolled gauze or wet tea bag over the extraction site and bite down HARD and STEADILY for another ½ hour to one hour. DO NOT LIFT UP THE GAUZE DURING THIS PERIOD TO SEE IF IT IS BLEEDING. ALSO DO NOT RINSE YOUR MOUTH OUT WITH WATER DURING THIS PERIOD. If bleeding continues after these two attempts to control the bleeding, please call us.

Ibuporofen or acetaminophen

Patients should be told to take what postoperatively to prevent initial discomfort before the effects of the local anesthetic disappear?

True

T/F: Pain is usually not severe and can be managed in most patients with over-the-counter analgesics

12 hours

When does peak pain experience occur post-op?

2 days

Significant pain from extraction rarely persists longer than __ days after surgery

Before local anesthetics subside

When should the first dose of analgesic medications be taken post-op?

True

T/F: Pain is much more difficult to manage if administration of analgesic medication is delayed until the pain is severe

60-90 min

How long does it take for analgesics to become fully effective?

400-800 mg, q4h (if 800 - q8h)

What is the ibuprofen dosage and frequency post-op for mild pain?

325-500 mg, q4h

What is the acetaminophen dosage and frequency post-op for mild pain?

- Codeine 15-60 mg

- Hydrocodone 5-10 mg

What analgesics are prescribed for moderate pain situations?

Oxycodone 2.5-10mg

What analgesics are prescribed for severe pain situations?

- Stomach ulcers

- Pregnancy

- Kidney/GI conditions

- Patient taking anti-coagulents (eliquis/xarelto or coumadin)

When can a patient not taken ibuprofen?

Acetaminophen (Tylenol)

What medication?

- Max: 4g/day (some recommend 3g)

- 325-650mg every 4-6 hours OR 975-1000mg every 6-8 hours

- 650mg every 6 hours allows concurrent or alternating doses with Ibuprofen

- Regular strength: 325mg

- Extra strength: 500mg

Ibuprofen (Motrin/Advil)

What medication?

- Max: 3200mg/day (some suggest 2400mg)

- 400-600mg every 4-6 hours

- 600mg every 6 hours allows concurrent or alternating doses with acetaminophen

- 800mg for anti-inflammatory dosing, typically every 8 hours

3200mg/day (some suggest 2400mg)

What is the maximum amount of Ibuprofen (Motrin/Advil) per day?

Calorie, volume

(First 12 hours should be soft and cool)

High-______, High-______ liquid or soft diet is best for first 12-24 hours post op

~2L

How much fluids should a patient drink in the first 24 hours post-op?

Several

Multiple extractions in all areas of the mouth, a soft diet is recommended for _________ days after the surgical procedure

True (May require consultation)

T/F: Diabetic patients should be encouraged to return to their normal insulin and caloric intake as soon as possible

C and D

On the day of surgery, what are patients told to do when they ask if they can brush their teeth?

A) No changes to normal hygiene routine

B) Do not brush or floss at all

C) Gently brush the teeth that are away from the

area of surgery in the usual fashion

D) Avoid brushing the teeth immediately adjacent

Post op day 1

When do you begin gentle rinses with dilute salt water?

POD 3-4

When do you return to normal oral hygiene routine post op?

36-48 hours

When does edema reach its maximum?

POD 3-4

When does edema usually subside?

End of first week

When does edema usually resolve?

Infection

If a patient has increased swelling after the 3rd day, what might this be an indication of?

20 minutes

Ice packs are recommended for swelling on the local area for ___ minutes on and then ___ minutes off for a period of 12-24 hours

Upright

Sleeping in a more _____ position by using extra pillows will help

True

T/F: A moderate amount of swelling is a normal and healthy reaction of tissue to the trauma of surgery

Trismus

What can results from trauma and the resulting inflammation involving the muscles of mastication?

Medial pterygoid

If a patient has trismus, it can be due to what muscle being penetrated by local anesthetic during IAN?

Trismus

What has the following characteristics?

- Results from trauma and the resulting inflammation involving the muscles of mastication

- May also result from multiple injections of the local anesthetic

- Medial pterygoid muscle may be penetrated by the local anesthetic needle during the inferior alveolar nerve block

- Usually not severe and does not hamper the patient's normal activities

- Patients should be warned

- May be indicative of infection depending on clinical scenario

Ecchymosis

ID the complication:

ecchymosis

What post-op condition?

- Blood oozes submucosally and subcutaneously

- Appears as a bruise in the oral tissues/face/ neck

Older

Ecchymosis is usually seen in what patient population due to...

- Decreased tissue tone

- Increased capillary fragility

- Weaker intercellular attachments

True

T/F: Ecchymosis is not dangerous and does not increase pain/infection

2-4 days

The onset of ecchymosis is usually ___ to ___ days after surgery

7-10 days

Ecchymosis usually resolves fully within ___-___ days

1 week (sutures removal)

When do you usually do a follow-up appointment?

infection

If a patient is 3 days post-op and has swelling, redness, fever or pain, what is your concern?

True

T/F: Must enter into the records a note of what transpired during each visit. A person with no background should be able to fully understand the context and history as well as what transpired

"Record of Procedure"

Define the following:

- Found in either Procedure Note or Emergency Procedure Note

- This is where you document what you did during a particular procedure