Subsequent to patch placement, Patient B notes that her nausea is resolving. The staff had ascertained the pertinent information; had a risk factor identification scale been utilized, the patient would have been ranked at a very severe level of risk for PONV. The anesthesiologist recognized this risk and treated Patient B with an appropriate dose of antiemetic prior to the termination of surgery.
There were omissions in care that could have reduced the risk of PONV development in this patient. Prior to the first dose of ondansetron in the operating room, a dose of dexamethasone could have been administered to enhance effectiveness of the serotonin antagonist. During the PACU phase of care, the nurse caring for Patient B instituted measures to manage both the patient's pain and nausea.
However, there were extenuating circumstances that were not considered and could have reduced the development of this complication. It was noted in the operative report that the patient had an episode of hypotension and blood loss; this volume depletion most likely increased the risk of PONV. In addition, the patient may have remained volume depleted into the PACU, and no note of this was made. The physician ordered the second PACU dose of ondansetron, which was administered without benefit.
The recommendation for rescue management of PONV is to change drug classes if one is not adequate; thus, another drug should have been ordered. The scopolamine patch seemed to have a beneficial response; upon further questioning of the patient, it was discovered that whenever she had previous bouts of motion sickness the patient used patches to help her manage her symptoms. Had this information been ascertained in the preoperative phase, the patch could have been applied preoperatively or in the operating room.
It is critical to gather as much information as possible to reduce these types of delays in patient management. Case Study Patient C is a high school senior.
During the opening drive in the Friday night football game, Patient C is hit from behind. When he falls, he sustains open, comminuted fractures of his left tibia and fibula. Because he is unable to stand, an ambulance is brought onto the field to transport the young player to the hospital for evaluation. Upon arrival at the emergency department, Patient C's leg is examined, x-rayed, and evaluated by the orthopedic surgeon on call.
It is determined that prompt stabilization and cleansing of the wound would be optimal for the best possible outcome; thus, Patient C is prepared for surgery. His parents, who were at the game, arrive in the emergency department just moments after the ambulance and are available to give permission for the operative procedure. As Patient C has been medicated for pain, a history is obtained from the parents.
There are no notable problems; Patient C is a healthy young man in excellent physical condition. He has not had previous operations and no previous exposure to anesthesia. Patient C is transferred to the operating room. The anesthesiologist gives the patient a number of preoperative medications, including those to prevent PONV. The anesthesia of choice is enflurane Ethrane , a volatile gas. The patient first receives succinylcholine prior to intubation, followed by the anesthetic gas.
Within minutes, the anesthesiologist notes that Patient C's carbon dioxide levels are beginning to rise. Just as the surgeon is to begin, the patient sustains a cardiac arrest. A code response is initiated by the remaining members of the operating team. The rescuer performing chest compressions notes that the patient's skin is warm. While resuscitative efforts continue, blood for laboratory evaluation is obtained.
The arterial blood gas results demonstrate a pH of 6. At this point, the anesthesiologist's suspicions are confirmed; the patient is experiencing an episode of malignant hyperthermia. The operating room personnel contact the PACU to ask for assistance in drawing up and preparing the dantrolene.
Only one nurse is available to leave the PACU, and she assists with mixing and administering the dantrolene as soon as it is prepared.
Additionally, the patient requires repeat doses of sodium bicarbonate to combat the falling serum pH. Within 15 minutes of administering the dantrolene, the patient begins to demonstrate a perfusing rhythm, although this is punctuated by frequent runs of premature ventricular contractions.
Antiarrhythmics are administered to control the cardiac complications. Simultaneously, the patient is cooled with external cold packs applied to the groin and axilla areas. The leg wound is dressed to prevent further contamination during the resuscitative efforts. Repeat blood is obtained for laboratory analysis.
The patient's potassium is elevated, and the patient is started on a glucose-insulin drip. After the patient's cardiac condition is stabilized, the operating room staff request transfer of the patient to the PACU for further management. The patient is moved, and the PACU staff becomes responsible for managing the patient. The antiarrhythmics, the glucose-insulin drip, and the cooling measures are continued.
During the first 30 minutes in the PACU, the patient's urine is noted to be a deep red color, indicative of developing rhabdomyolysis and potential renal failure.
Within 20 minutes, the urine lightens in color, although it retains a reddish tinge. Approximately three hours after the first cardiac arrest, the patient suffers a second arrest with the development of ventricular fibrillation. A second code response is called, and the patient is again resuscitated with dantrolene, antiarrhythmics, and sodium bicarbonate. Once again, the patient responds to treatment and regains a perfusing cardiac rhythm.
The patient is ordered to receive dantrolene every 4 hours for the following 48 hours to ensure that another episode of malignant hyperthermia does not develop. The patient is subsequently stabilized and transferred to the ICU, where he remains for 72 hours. Case Study Discussion Patient C is a perfect candidate for the development of malignant hyperthermia. He is a young male with well-developed musculature. He has had no previous exposure to anesthesia, so his history was not negative for anesthesia complications; it was incomplete.
The onset of cardiac arrest was quite rapid in this patient. This devastating complication can be quick in onset, as demonstrated here, or may be delayed and occur later during the operative procedure.
The first indication of the development of malignant hyperthermia in this patient was the rising carbon dioxide level. The skin temperature remained normal during the early phase of development; the first person to note the rise in body temperature was the rescuer performing chest compressions.
The patient was managed appropriately. The staff was required to perform a number of actions to save this patient's life. Administering medications, preparing those medications, cooling the patient, and monitoring blood laboratory values is only part of the picture.
The additional PACU nurse pulled to the operating room to help with the resuscitation was instrumental in providing the additional hands and expertise needed in this case. Upon arrival in the PACU, the patient continued to require extensive stabilization measures. The repeat dantrolene had been ordered but had not yet been administered when the patient sustained the second cardiac arrest.
It is imperative that the administration of repeat doses of dantrolene be continued to prevent this type of occurrence. Fortunately, the patient was young and healthy and responded to the treatment. Long-term outcome for this patient was excellent. The resuscitative efforts were exceptional, and the patient did not sustain any long-term neurologic deficits.
It is important to point out that the patient did not have his fracture stabilized at this time. Subsequent surgery was delayed to ensure the stability of the patient. Once stable, the patient had the orthopedic repair performed with epidural anesthesia. Although the risk of developing malignant hyperthermia again while undergoing epidural anesthesia is small, dantrolene was used prophylactically to ensure patient stability throughout the procedure.
Case Study Patient D is a male patient, 32 years of age, undergoing an uncomplicated bowel resection to repair damage and scarring of the bowel secondary to a traumatic automobile accident five years prior.
The patient is a healthy, active male who states that he has smoked a pack of cigarettes a day off and on for the last 15 years. He had quit smoking after his auto accident but started again three years previously. His history is unremarkable for cardiovascular disease, and his anesthesia provider has reviewed his previous surgeries, performed at the time of the accident.
During surgery, the patient receives general inhalation anesthesia, intravenous narcotics, and neuromuscular blocking agents. The procedure runs approximately four hours in length.
During the procedure, the patient has one short episode of hypotension that was managed with volume replacement. The patient had been extubated in the operating room just prior to transfer to the PACU. The nurse caring for the patient notes the signs and symptoms of respiratory distress, including the high respiratory rate, the shallow respirations, and the low oxygen saturation level. When the patient awakens complaining of pain, the nurse is hesitant to give too large of a dose of the narcotic that had been ordered.
However, the patient continues to complain of ongoing pain, and the nurse leaves the patient's bedside to obtain the narcotics. Upon returning to the patient, the nurse finds the patient dozing. When the patient wakes, the nurse asks him to use the incentive spirometer; he had been instructed in its use in the preoperative phase of care.
The patient complains of increasing abdominal pain and refuses to use the spirometer. At this point, the nurse chooses to administer 3 mg of hydromorphone as ordered for pain by the surgeon.
After receiving the hydromorphone, the patient again dozes off and appears to be comfortable. The patient has oxygen supplied by nasal prongs, and the nurse chooses not to intervene further.
The patient is left sleeping while the nurse assists in the admission of another patient to the PACU. The nurses immediately call a code and initiate resuscitative measures. The patient is administered naloxone, and positive pressure ventilation is initiated.
However, bagging the patient is extremely difficult; the pop-off valve goes off with each ventilation, and the patient's chest is not rising as hoped. Fortunately, the anesthesia provider responds and immediately asks for an endotracheal tube to reintubate the patient.
When attempting to intubate the patient, the anesthesia provider finds it very difficult as a result of the patient developing a laryngospasm. Succinylcholine is administered, and high positive pressure oxygen is given via a jet vent. After another two attempts, the patient is successfully intubated. The patient is then placed on a mechanical ventilator with positive-end-expiratory pressure applied to help reduce the buildup of fluid in the lungs.
He is started on a course of antibiotics and steroids and admitted to the ICU. After two days, the patient is extubated, moved to the surgical floor, and at day 6, is discharged from the hospital. Case Study Discussion Patient D is a typical postoperative patient.
He was healthy and had an uncomplicated surgical event. He should have progressed through the recovery period without a problem; however, he sustained a respiratory arrest and his recovery was prolonged.
Fortunately, he survived without long-term sequelae. The nurse caring for Patient D made assumptions about his condition based upon his preoperative history. The smoking history allowed her to be lulled into a sense of security knowing that smokers have altered oxygen saturations. His appearance of ease was comforting, and she became complacent in her vigilance. When Patient D sustained the respiratory arrest, the initial cause was unknown.
He had a number of risk factors; the arrest may be been caused by the dose of narcotics, in which case, naloxone would have been a treatment of choice. This was tried but without a successful response. He was hypoxemic upon arrival in the PACU, as evidenced by his low oxygen saturations. This hypoxemic state may have precipitated the respiratory arrest. In addition, he had received neuromuscular blocking agents in the operating room and the arrest may have been secondary to residual paralytic agent.
However, upon intubation he was noted to have developed a laryngospasm, which may indicate that he sustained an episode of NCPE. He was a candidate for NCPE due to his age, preoperative health status, and early extubation. Whenever a patient sustains a life-threatening event such as a respiratory arrest, it is critical that care providers work to determine the cause. Identification of the cause can lead to the appropriate choice of a resuscitative effort.
In this case, the nurse acted appropriately in administering the naloxone, although it was later determined that this was not the cause of the arrest. Despite the fact that NCPE was not considered until the patient was found to have a laryngospasm, the measures undertaken were appropriate. The only error was the complacency that the nurse exhibited towards the patient's status upon arrival in the PACU and the first 45 minutes of care.
Early attention to the hypoxemic state may have prevented the development of the arrest, although this does not always make a difference in cases of NCPE. Patient D should be educated prior to discharge regarding the development of this side effect.
If further surgeries are needed, it is imperative that he be able to relate this information so that measures can be instituted to reduce the risk of respiratory compromise. The patient has a history of significant vascular compromise of his left leg secondary to the blockage. A stent is placed during surgery, and the patient is subsequently transferred to the PACU. The patient was extubated prior to arrival in the PACU.
After the patient is stabilized and an assessment is completed, he is warmed using a warm air convection device. To combat his low oxygen saturations, his oxygen flow is increased to 6 liters per nasal cannula. Fifteen minutes after arrival, the patient complains of severe pain in his left leg. His peripheral pulses are good, and his color is pink. However, as this was the surgical site, the nurse immediately contacts the surgeon.
The surgeon speculates that the pain is secondary to new perfusion in this leg and the removal of sequestered by-products of circulation. He orders the patient to receive 3 mg hydromorphone for pain, which helps resolve the patient's complaints. At this point, he complains of pain in both lower extremities.
Upon assessment, it is found that his peripheral pulses are weak in the right leg and the color of this extremity is dusky and cool to touch. His left leg remains warm, pink, and with good peripheral pulses. The patient's legs are elevated on a pillow to improve blood return to the heart, and he is again administered hydromorphone.
After the second dose of hydromorphone, the patient drifts off to sleep. When he wakes, he continues to complain of pain in both extremities. The right leg remains cool, dusky, and with poor peripheral perfusion. The nurse again contacts the surgeon, who determines that the patient is possibly developing a DVT in the right calf. The patient has graduated compression stockings applied to the right leg to reduce the risk of further clot formation.
As the patient had been heparinized in the operating room, no further anticoagulants are ordered. The patient is discharged from the PACU to the surgical ward. At day 3, when he is ambulating in the hall, Patient E suffers a cardiac arrest and is not able to be resuscitated.
He most likely sustained a pulmonary embolus secondary to the DVT in the right leg. The ambulation may have caused the clot to be knocked loose, allowing it to travel to the pulmonary vasculature.
Case Study Discussion This patient was at high risk for DVT formation both due to the type and extent of surgery as well as his history of peripheral vascular disease. As he was anticoagulated in the operating room, no further interventions were instituted. However, the guidelines for management and prophylaxis of this type of patient recommend the institution of graduated compression stockings or intermittent pneumatic compression device in addition to anticoagulation .
It can be speculated that this may have reduced his incidence of DVT formation; however, due to his extensive vascular history, he was at high risk prior to, during, and after surgery. It would be speculation to determine if this event may have been preventable. The nurse caring for the patient performed her job according to policy. The only change that may have been recommended is the placement of the graduated compression stockings on the right leg prior to surgery or after the patient was stabilized in the PACU.
Case Study Patient F, a woman 47 years of age, has sustained a comminuted fracture of her left tibia and fibula after falling on wet grass. Patient F is transferred to the emergency department, where the determination is made to take her to the operating room for internal fixation and subsequent casting. The leg is elevated on top of pillows to ensure adequate drainage. Upon awakening, the patient complains of pain of 9 on a point scale.
She is medicated with hydromorphone and falls back to sleep. Forty-five minutes later, she again complains of continued pain. At this point, she receives 3 mg of intravenous morphine. While reviewing the patient's chart and medication orders, the PACU nurse discovers that the patient has a history of frequent narcotic use and is labeled a "complainer" who is frequently seen in the emergency department or physician's office with vague complaints of pain and requests for refills of her narcotics.
After two hours in the PACU, the patient is transferred to the orthopedic floor for continued recovery. Other than her complaints of pain, her PACU stay is uneventful.
When giving report to the nurses on the floor, the PACU nurse relays her findings regarding the patient's complaints of pain and repeat requests for pain medications. During the remainder of the day and into the evening shift, the patient is monitored every four hours.
She is medicated as ordered, but within one to two hours after receiving her medications she calls the nurse for additional narcotic. She continues to complain of pain, stating that she feels a burning sensation in her left leg. Her cast is checked and appears to be intact, without peripheral swelling of her leg, and peripheral pulses are present but weak. At midnight, the patient calls the nurse with continued complaints of pain. The nurse notes that the cast is tight; the patient is no longer keeping it elevated as instructed.
The orthopedist on call is contacted, and the decision is made over the telephone to bivalve the patient's cast to ensure adequate circulation. This is accomplished, and the patient appears more comfortable, although her reported pain score remains at 6.
The following morning the patient is seen by the orthopedic surgeon, who notes the bivalved cast and continued complaints of pain.
The surgeon orders the cast to be replaced, which is accomplished. That evening the patient again complains of pain, this time giving a score report of The physician is again contacted by telephone, and additional pain medications are ordered.
Throughout the night, the patient continues to complain of pain despite frequent doses of narcotics. The patient is scheduled for discharge in the morning. When seen by the surgeon prior to discharge, it is noted that the patient's foot is cool to touch and peripheral pulses remain weak. She has continued complaints of pain and does not want to be discharged at this time. At this point, the surgeon considers the possibility that the patient may be developing a case of compartment syndrome.
The cast is removed, and the extremity is tense and cool, with poor color. The patient is immediately taken to the operating room, where a fasciotomy was performed. Upon opening the compartment, it is noted that there is extensive necrotic tissue that requires debridement.
The remaining amount of muscle is minimal. The patient eventually recovers but with severe disability in her ambulatory capabilities. Case Study Discussion This patient sustained a long-term disability secondary to rapidly developing compartment syndrome. As discussed, rapid assessment and intervention is required to prevent this type of sequelae. The classic sign of compartment syndrome is pain that is out of proportion to the injury.
This patient had continued complaints of pain; however, due to her history as someone who was always complaining of pain, her complaints were not taken seriously. All patient complaints should be addressed and believed; the lack of attention to these complaints led to a long-term disability in this patient. Compartment syndrome is a common complication following fracture, and the possibility of this complication should have been recognized earlier.
In fact, the first evening, when the first cast was bivalved, compartment syndrome should have been considered. It was more than 36 hours before the diagnosis of compartment syndrome was made, enough time for severe tissue necrosis to develop. Had the patient undergone a fasciotomy rather than bivalving the cast, the outcome may have been different.
This case demonstrates the need for prompt recognition of patient's complaints and consideration of all potential complications, regardless of the patient's previous history. The nurses and physicians in this case neglected the patient's pain complaints because of her prior history. The patient should have been given the benefit of the doubt, which may have allowed for earlier intervention.
This case subsequently went to litigation. The physicians involved in her care admitted to malpractice in neglecting to recognize and diagnose the development of the compartment syndrome earlier in her care when the potential for complications may have been decreased. The nurses admitted to malpractice as they chose to disregard the patient's complaints when further investigation should have been undertaken.
It is a sad outcome, especially as it was a preventable complication. Case Study Patient G is a man, 83 years of age, who is undergoing colon resection for removal of cancerous nodes.
The operative procedure proceeds without complication, and the patient is transferred to the PACU without incident. During the first postoperative hour, the patient is noted to be hypotensive, with a systolic blood pressure of 80 mm Hg. A review of the patient's history indicates that his normal systolic pressure on admission was mm Hg. The patient is noted to take furosemide, hydrochloride thiazide, metoprolol, and lisinopril for blood pressure control.
With this information in mind, it is obvious that the patient's systolic pressure is significantly lower than anticipated. Upon awakening, the patient is confused and disoriented. He needs continual reminders to help orient to person, place, and time.
He is not compliant with postoperative instructions and tries to remove the dressing from his abdomen. He complains of pain when asked but is not able to rate the pain on a scale of 1 to He requires wrist restraints to prevent him from disrupting the surgical site.
The patient is also noted to have a history of congestive heart failure following myocardial infarction many years ago. While fluid resuscitation would be the first step in supporting the patient's blood pressure, the risk of developing further cardiac failure should be considered.
Prior to instituting further management, the patient's history and medication use is reviewed. The patient stated upon admission that he had been NPO after midnight, as instructed. He was told to take his medications in the morning with a small sip of water prior to arriving at the hospital, with which he complied.
His wife told the nurses that he did not eat the food recommended on his bowel prep program the evening prior to surgery; he was anxious and wanted to ensure that his colon had been cleaned out sufficiently.
His wife also noted that he had complied with the bowel prep cleansing as instructed. He is finally discharged from the PACU five hours after surgery and transferred to the surgical ward.
On the surgical ward, his blood pressure remains low, with an average systolic pressure of 90— mm Hg. Case Study Discussion This case presents the typical complication of under-resuscitation and subsequent volume depletion. The patient's response to this complication was the development of a prolonged hypotensive episode, complicated by confusion and disorientation upon awakening.
Further history should have been ascertained from the patient and the patient's wife prior to surgery. The staff was unaware that the patient had been NPO for such a length of time. When asked if he complied with the bowel cleansing as ordered, the patient replied yes; no further questions were asked to ensure how he complied, when he last ate, etc. This assumption increased the risk of compromise. In addition, the patient took his normal blood pressure control medications prior to surgery.
While holding of these medications is often done on the day of surgery, the nurses needed to recognize the potential risk this offered. Ensuring adequate resuscitation and volume status in the preoperative and operative phases of care should have been instituted. Anesthetic agents are vasodilators. This combined with the administration of blood pressure reducing agents caused a significant drop in the patient's systolic pressure.
The patient's systolic pressure remained low even at the time of discharge; it is critical to alert this patient to this development and ensure that the patient follow up with either the surgeon or the cardiologist. As the drugs cleared from the patient's body, the normal systolic pressure should have been achieved. The confusion and disorientation that developed in the PACU was most likely a consequence of low perfusion pressure within the cranial cavity of this patient. There are a number of reasons for postoperative confusion in the elderly; those reasons should be identified and treated.
In this case, had the patient received fluid resuscitation earlier in the course of care, this neurologic development may have been avoided. Managing the elderly patient with a history of multiple disease processes, medication use, and anesthetic administration is challenging.
Further in-depth evaluation and history taking is critical to ensure safe care delivery throughout the operative period. In the operating room, the patient's disease was found to be extensive, and he now has an ileostomy for stool drainage. He had a large mid-line incision reaching from the pubis to the distal sternum. He is somnolent but opens his eyes upon repeated commands. The formation of the stoma was discussed with the patient prior to surgery as a last choice option; however, he was unaware at that point in his care of the extent of his disease and the need for the ileostomy.
Measures to rewarm the patient are undertaken. He continues to sleep, although he is arousable. It is also noted that urine output is only 5—10 mL of dark yellow urine in the Foley catheter tubing. The physician is notified, and she orders a fluid challenge of mL. Although this is below baseline, it does show improvement.
Postoperative pain studies lack standardization and are at some points conflicting; however, in general, it could be inferred that women might experience pain more often and to a greater extent than men 58 , 65 , 66 , 67 , Although the research in this regard is rather scarce in terms of postextraction pain by gender, the aforementioned results could imply that females might have a higher sensitivity to pain stimuli perhaps due to psychosocial factors mood, sex role beliefs, pain coping strategies, and pain-related expectancies , catastrophizing and sex hormones 38 , 69 , Also the thinner mandible of women might render them more vulnerable to pain and some complications after dental procedures 6 , Some authors have reported more intense postsurgical pains 28 , 29 , 40 , longer symptom recovery times 17 , 47 or neurosensory deficit in females However, many others found conflicting results 4 , 12 , 15 , 37 , 38 , 46 , 57 , 72 , Capuzzi et al.
Yuasa and Sugiura 37 declared that postoperative swelling and morbidity but not pain might be greater in females. This controversy might be rooted in various missing latent variables e.
Oral contraceptives Contraceptive consumption might be less likely to affect or confound pain-related results 4 , 12 , 38 , 74 , although a few studies have reported on its positive role in this regard as well Regardless, modern contraceptive pills contain considerably lower doses of estrogen and therefore have a reduced role compared with those of the past 34 , Age The production and process of sensory stimuli might be influenced by aging 77 , 78 , The elderly could be at higher risk of complications, such as severe pain and sensory disturbances 4 , 12 , 38 , 80 , 81 , possibly because of this group's poorer healing potential, denser bones and completed dental roots 4 , 28 , 34 , Some investigators have observed significant deteriorating effects of aging on pain 9 , 12 , 28 , Blondeau and Daniel 34 reported increased neurosensory problems in patients older than 24 years.
However, other studies have not identified such a role 29 , 39 , Adeyemo et al. Yuasa and Sugiura 37 reported a significant influence of age on swelling and collective postprocedural morbidity but not pain. In the study of Capuzzi et al. Haraji and Rakhshan 15 studied younger patients and showed that when the effects of the operation difficulty, smoking and gender were not controlled for, younger people might show significantly greater pain.
However, when these factors were adjusted for, younger patients showed a borderline significantly greater amount of pain only for the first postoperative day but not on the third postsurgical day The narrow range of patient ages could mask such an effect, since third molar extraction is usually indicated in young ages 38 , and debilitating effects of age might appear in older ages Some authors have advocated the removal of impacted molars in young adults to avoid severe or permanent sequelae 9 , 34 , Nonetheless, if the assumption is not confirmed, early prophylactic extraction of wisdom teeth, which is common in Europe and America, might not be justifiable 38 , 84 , Conclusion Based on the number of studies agreeing that a certain potential factor might likely be a real risk factor Table 1 , the trauma of surgery and experience of the surgeon were more likely to be causative or risk factors of pain.
High levels of estrogen were not necessarily a risk factor for pain. Evidence suggesting a higher incidence of postextraction pain in females was outnumbered by reports that refuted such an association. The effect of age remained inconclusive. Although only a few studies regarding the effect of oral hygiene on postoperative pain exist, it was shown to be effective in that regard as well. There were at least three obstacles for detecting possible links between pain and risk factors: consumption of painkillers and antibiotics by the patients after surgery, which act as efficient confounders 15 , 20 , 25 , as well as poorer statistical approaches, and confusion of pain caused by a dry socket or infection with pain caused only by the surgery and also with discomfort.
Except for a few essays 15 , almost all previous studies have failed to distinguish dry socket or infection pain from pain caused by the surgery alone when evaluating the risk factors for postoperative pain.
Future studies are warranted to account for each type of pain independently. Another issue ignored in almost all studies except a few 15 , 28 , 31 is that the variables that affect pain likely interact with each other.
Therefore, analyses not accounting for the interactions are less accurate and less useful than those that consider a broader clinical picture Table 1 A summary of studies supporting or not supporting the role of the searched risk factors some studies fit both criteria Vahid Rakhshan: Common risk factors for postoperative pain following the extraction of wisdom teeth. References 1. Nordenram A. Postoperative complications in oral surgery. A study of cases treated during Swed Dent J.
The relationship of cigarette smoking to postoperative complications from dental extractions among female inmates.
A randomized double blind clinical study on the efficacy of low level laser therapy in reducing pain after simple third molar extraction. Maced J Med Sci. Types, frequencies, and risk factors for complications after third molar extraction.
J Oral Maxillofac Surg. Oral hygiene and postoperative pain after mandibular third molar surgery. Prediction of post-operative facial swelling, pain and trismus following third molar surgery based on preoperative variables. Calhoun NR. Dry socket and other postoperative complications.
Dent Clin North Am. Factors predisposing to postoperative complications related to wisdom tooth surgery among university students. J Am Coll Health. A prospective study of complications related to mandibular third molar surgery. Third molar surgery: an audit of the indications for surgery, post-operative complaints and patient satisfaction. Br J Oral Maxillofac Surg. Predictor evaluation of postoperative morbidity after surgical removal of mandibular third molars. Acta Odontol Scand.
Extraction of impacted third molars. A longitudinal prospective study on factors that affect postoperative recovery. Relationships between surgical difficulty and postoperative pain in lower third molar extractions. Pedersen A. Interrelation of complaints after removal of impacted mandibular third molars. Int J Oral Surg. Haraji A, Rakhshan V.
Chlorhexidine gel and less difficult surgeries might reduce post-operative pain, controlling for dry socket, infection and analgesic consumption: a split-mouth controlled randomised clinical trial. J Oral Rehabil. Prognostic factors affecting the duration of disability after third molar removal. Wardle J. Dental pessimism: negative cognitions in fearful dental patients. Behav Res Ther. Third molar surgery and associated complications. Effects of intraalveolar placement of 0.
J Orofac Pain. Blum IR. Contemporary views on dry socket alveolar osteitis : a clinical appraisal of standardization, aetiopathogenesis and management: a critical review. Int J Oral Maxillofac Surg. Bloomer CR. Alveolar osteitis prevention by immediate placement of medicated packing. Modern concepts in understanding and management of the "dry socket" syndrome: comprehensive review of the literature.
Clinical concepts of dry socket. Prevention of alveolar osteitis with chlorhexidine: a meta-analytic review. Alveolar osteitis: a comprehensive review of concepts and controversies.
Int J Dent. Recovery after third molar surgery: clinical and health-related quality of life outcomes. Risk factors associated with prolonged recovery and delayed healing after third molar surgery.
Mandibular third molar removal: risk indicators for extended operation time, postoperative pain, and complications. Logistic regression analysis of risk factors for the development of alveolar osteitis.When attempting to intubate the patient, the anesthesia provider finds it very difficult as a result of the patient developing a laryngospasm. Upon arrival at the emergency department, Patient C's leg is examined, x-rayed, and evaluated by the orthopedic surgeon on call. Although only a few studies regarding the effect of oral hygiene on postoperative pain exist, it was shown to be effective in that regard as well. Postoperative complications in oral exam. In the study of Capuzzi et al. The only collection in care was the delay in addition propaganda essay prompts for college warm the outcome. The smoking meaning allowed her to be lulled into a certain of security knowing that students have altered oxygen saturations. It is vulnerable that the surgery will be very pending resolution of the abdominal distension. The coeducation is subsequently stabilized and transferred to the ICU, where he makes for 72 hours.
Although the risk of developing malignant hyperthermia again while undergoing epidural anesthesia is small, dantrolene was used prophylactically to ensure patient stability throughout the procedure. During surgery, the patient receives general inhalation anesthesia, intravenous narcotics, and neuromuscular blocking agents. The antiarrhythmics, the glucose-insulin drip, and the cooling measures are continued. The ambulation may have caused the clot to be knocked loose, allowing it to travel to the pulmonary vasculature. The patient is arousable but sleeping when not stimulated. All patient complaints should be addressed and believed; the lack of attention to these complaints led to a long-term disability in this patient.
After four hours in the PACU, she is transferred to the inpatient unit for an overnight stay. Dental pessimism: negative cognitions in fearful dental patients.
They also found a correlation between this phenomenon measured immediately after the extraction and painful sockets She is nervous prior to surgery, yet anxiously awaiting the new life that she sees in her future. During the first postoperative hour, the patient is noted to be hypotensive, with a systolic blood pressure of 80 mm Hg.
This period of decreased circulating volume could have potentiated the risk of subsequent ileus formation. Case Study Patient G is a man, 83 years of age, who is undergoing colon resection for removal of cancerous nodes. Pedersen A. He was on the floor for an indeterminate amount of time prior to being found by a neighbor who checked on him when he had not been seen for a number of hours. The patient has a gastric band placed, creating a small pouch.
The confusion and disorientation that developed in the PACU was most likely a consequence of low perfusion pressure within the cranial cavity of this patient.
Re-intubation would have to be performed with extreme caution to prevent damage to the surgical repair. As Patient C has been medicated for pain, a history is obtained from the parents.
These factors trauma, duration of surgery and anxiety can play important roles in inducing complications 8 , 12 , 22 , 28 , 29 , 30 , 47 , 48 , 49 , 50 , 51 , 52 , One procedure that may be beneficial for these patients is the insertion of a tube into the stoma. The patient stated upon admission that he had been NPO after midnight, as instructed. Although the risk of developing malignant hyperthermia again while undergoing epidural anesthesia is small, dantrolene was used prophylactically to ensure patient stability throughout the procedure. The elderly could be at higher risk of complications, such as severe pain and sensory disturbances 4 , 12 , 38 , 80 , 81 , possibly because of this group's poorer healing potential, denser bones and completed dental roots 4 , 28 , 34 , When he falls, he sustains open, comminuted fractures of his left tibia and fibula.
She started an exercise regimen and is determined to continue with her weight loss. The anesthesia of choice is enflurane Ethrane , a volatile gas. Prior to instituting further management, the patient's history and medication use is reviewed. Her mother is trying to calm her, but the child does not appear to recognize her mother or at least does not respond to the mother's efforts. It would be optimal to awaken the patient to have her participate in respiratory exercises; however, she remains quite sleepy while in the unit.
This assumption increased the risk of compromise. Surgical intervention using the laparoscopic approach is successful. Therefore, expert clinicians might obtain better results 8 , 12 , 34 , 48 , 49 , 50 , 51 , 54 , 55 , One measure that may be used to improve oxygenation in patients following surgery is respiratory exercises to help expand the lungs and encourage the patient to expel secretions. After the patient is stabilized and an assessment is completed, he is warmed using a warm air convection device. Postoperative pain studies lack standardization and are at some points conflicting; however, in general, it could be inferred that women might experience pain more often and to a greater extent than men 58 , 65 , 66 , 67 ,
When attempting to intubate the patient, the anesthesia provider finds it very difficult as a result of the patient developing a laryngospasm. The concern developed when the patient began to awaken and tried to remove the tube. Patient J's poor health status put him at increased risk for complication development.
Since the risk factors for postoperative pain have never been summarized before while the risk factors for dry socket have been highly debated, this report summarizes the literature regarding the common predictors of postextraction pain. To accomplish this goal, the patient should be cooperative and have an appropriate cognitive level to follow the commands. Meechan et al.