postoperative cancer care

© Ramaiah University of Applied Sciences

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Faculty of Dental Sciences

Post operative cancer care

Dr Zeeshan Arif


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CONTENTS

• Introduction

• Ventilation and oxygenation

• Recovery from GA

• Pain management

• Monitoring

• Respiratory care

• Post op HB

• Safe allowable blood loss

• Wound care

• Flap care

• Fluid balance

• Maintainace of mouth hygiene

• Mobilization

• Drains and catheders

• Communication

• Nutrition

• Deep vein thrombosis

• Hospital acquired infection

• References


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Introduction

• Good post-operative management will have started before the

procedure with appropriate counselling and preparation

• This preparation will have included an assessment of fitness for the

procedure and identification and management of any risk factors.

• The patient will have been provided with a clear explanation of the

procedure, the risk-benefits and the likely outcome.

• The patient's expectations match those of the health professional.


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• The postoperative period begins when surgeons place the last

suture and prepare to remove the surgical drapes.

• The first postoperative concern is the removal of the throat pack if

one was placed.

• Before a throat pack is removed, the mouth should be suctioned to

remove debris and blood clots and the surgeon should keep the

suction going until the throat pack has been removed fully.


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• A good throat pack is one that, when

removed, may be bloody or ‘‘dirty’’ at the

oral end but generally clean on the

tracheal end.

• The removal of the throat pack should be

verified by the surgeon, circulating nurse,

and anesthesiologist.

• The surface of the tongue should be

wiped clean, as residual blood on the

tongue may cause nausea and vomiting.


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Ventilation and oxygenation

• Because most oral and maxillofacial surgical procedures potentially

can compromise the airway, special attention must be paid to

maintaining a patent airway.

• It is the responsibility of oral and maxillofacial surgeons and

anesthesiologists to assure that the airway is protected during and

after surgery.

• Assisted ventilation should be done until patients are able to

maintain ventilation without an anesthetist telling them to breathe.

Post operative care of oral and maxillofacial surgery patient Orrett ogle. Oral and maxillofacial clinics of north America


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• Keeping the bed head elevated assists breathing and the

management of oral secretions by patients.

• If it is necessary to reverse patients for respiratory depression with

either naloxone (Narcan) or flumazenil (Romazicon), patients should

be observed for at least 2 hours.

• Incomplete reversal of muscle relaxants is the most common cause

in the hospital setting (oversedation is the most common cause in

the office).


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• When patients are not warmed during surgery and are cold, the

reversal of muscle relaxants may not be complete, and cold patients

that seem fully reversed can become reparalyzed as they warm up.

• The peripheral vasoconstriction traps the muscle relaxant in the

tissues, and as patients become warm and the vessels redilate, the

muscle relaxant returns into the circulation and becomes active.

• Patients should be reversed adequately and kept warm


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• Hypoxia is the major concern in the early postoperative period and

its incidence is high.

• Anesthesia depresses respiration and produces ventilation-perfusion

(V/Q) mismatch and pain and shivering that increase the demand for

oxygen.

• After general anesthesia, there always is some degree of alveolar

collapse resulting from a decrease in the functional residual capacity,

which may take days or weeks to return to baseline.


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Recovery from general anaesthesia

• Recovery is a gradual process, dependent on the continued

redistribution of the anaesthetic drug in the body together with

elimination or metabolism.

• The process is timed to result in emergence from anaesthesia as

close as possible to the completion of the surgery.

• A considerable residue of drug may remain, especially in skeletal

muscle, so that secondary peaks can occur in the plasma

concentration following rewarming and restoration of muscle blood

flow.


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• The slow release of the drug from muscle and fat prevents full

recovery of cognitive function for many hours and will potentiate

the effects of any additional sedative drugs.


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Pain management

• The World Health Organization (WHO) recommended a simple and

well-validated stepped regimen for the treatment of pain according

to intensity – known as the WHO ladder.

• The five essential concepts in the WHO approach to drug therapy of

cancer pain are:

• by the mouth

• by the clock

• by the ladder

• for the individual

• with attention to detail.


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• Acetaminophen, aspirin, or other nonsteroidal anti-inflammatory

drugs (NSAIDs) (e.g., naproxen, diclofenac, or indometacin)

• When pain persists or increases, an opioid such as codeine or

hydrocodone should be added (not substituted) to the NSAID.

• Persistent pain, should be treated by increasing opioid potency

(mainly morphine, methadone, or fentanyl).

• When patients cannot take medications orally, the other less

invasive routes (rectal or transdermal) should be tried; parenteral

routes, such as subcutaneous or intravenous, should only be used

when simpler methods are unavailable or ineffective


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Therapeutic approach Technique

Non-invasive pharmacologic

therapy

Oral, rectal, transdermal, subcutaneous, or intravenous

administration of NSAIDs, opioids and adjuvant drugs

Invasive interventions Peripheral nerve blocks

– Maxillary nerve

– Mandibular nerve

– Glossopharyngeal nerve

Ganglion blocks

– Sphenopalatine ganglion

– Trigeminal ganglion

– Stellate ganglion

Central neuraxial techniques

– Intraventricular opiates

– Intrathecal pump


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Intervention Advantages Disadvantages

Oral NSAIDs – Useful for mild to moderate pains

– Widely available, some over the counter

– May be combined with opioids

– Can be administered by patient or carer

– Ceiling effect to analgesia

– Side effects, especially gastritis and

renal toxicity

– May increase risk of bleeding

Oral opioids – Effective for both localised and generalised

pain

– Sedative and anxiolytic properties useful in

some acute treatment settings

– Can be administered by patient or carer

– Long acting, controlled-release forms

available

– Side effects may limit analgesic

effectiveness

– Prescription of these substances is

regulated

– Stigma associated with use fears

Transdermal opioids

(fentanyl)

Long duration of action (48–72 h) Difficult to modify dosage rapidly

Relatively slow onset of action

Subcutaneous

infusion

– Can provide rapid pain relief

– Morphine and its derivates are the preferred

drugs

– Only a limited volume can be

administered

– Induration and irritation at infusion

site

Intravenous infusion – Can provide rapid pain relief

– Almost all opioids can be given by this route

– Infection and obstruction of

intravenous lines are not uncommon

Epidural, intrathecal,

and intraventricular

routes

– Indicated for pain that does not respond to

less invasive measures

– Local anaesthetics may be added to spinal

opioids

– Tolerance may occur

– Infection at catheter site can produce

meningitis and/or epidural abscess

– Pruritus and urinary retention are not

uncommon


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Monitoring

• The vital signs (blood pressure, pulse, O2 saturation and respiratory

state) will be measured and recorded regularly.

• If an arterial catheter has been inserted, blood pressure and pulse

readings can be observed on a monitor constantly.

• Measurement of the central venous pressure may be required for

patients with poor cardiorespiratory reserve or where there have

been large volumes of fluid administered or major fluid shifts are

expected.

• The patient chart will also record all fluid that has been given during

and since the operation, together with fluid lost.


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Respiratory care

• Mechanical ventilation may be required in the early

phase of recovery.

• This can vary from prolonged endotracheal intubation,

to intermittent positive pressure ventilation, to

supplemental oxygenation by facemask or nasal

prongs.

• In these instances the patient may require prolonged

monitoring in an intensive care or high dependency

unit with regular assessment of oxygen saturation

(pulse oximetry and arterial blood gas analysis).


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Post op hb

Practice Guideline 2006 American Society of Anesthesiologists

• Hb less than 6.0 g/dL is a strong indication for

transfusion.

• There should be no blood transfusion if Hb is

higher than 10.0.

• For between 6.0 to 10.0 g/dL, it is based upon

the best clinical judgments, such as evidence of

organ ischemia, bleeding, intravascular volume,

and patients’ own risk factors, which can

predispose patients to have low cardiopulmonary

reserve and high O2 consumption


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Safe allowable blood loss

• The average blood volume that a patient may lose and still maintain

hemoglobin at a safe level is about 25% of hemoglobin drop from

baseline.

• This recommended 25% threshold can actually result in numbers

that are higher than most physicians expect.

• For example, a 25% loss of a start hemoglobin 13.0 g/ dL would be

as high as 9.75; a 25% loss of hemoglobin 12.0 g/ dL would be as

high as 9.0


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Wound Care

• Most surgical wounds undergo primary closure in which there is

minimal tissue loss and the wound edges can be satisfactorily

approximated.

• In the initial phases of healing, there is only minimal tensile strength

in the wound as remodelling of the collagen fibres has not occurred.

• As such, additional support in the form of sutures, staples or tapes is

required until full remodelling and epithelialisation occur.


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Recommendations for preventing SSIs in the post-operative

phase

Dressing and cleaning the wound

• Use an aseptic technique for changing or removing dressings

• untouched for up to 48 h after surgery, using sterile saline for wound

cleansing during this period only if necessary

• Use an interactive dressing for surgical wounds that are healing by

secondary healing

• Refer to a tissue viability nurse (or another healthcare professional

with tissue viability expertise) for advice on appropriate dressings

for surgical wounds that are healing by secondary intention


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Antibiotic treatment

• If a SSI is suspected (ie. cellulitis), either de novo or because of

treatment failure, give the patient an antibiotic

• Choose an antibiotic that covers the most likely causative organisms.

• Consider local resistance patterns and the results of microbiological

tests


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Common pathogens associated with types of operation

Type of operation Common pathogens

Abdominal surgery Gram-negative bacilli, anaerobes, streptococci

Breast surgery S. aureus, coagulase-negative staphylococci

Cardiothoracic surgery S. aureus, coagulase-negative staphylococci

Head and neck surgery S. aureus, coagulase-negative staphylococci

Neurosurgery S. aureus, coagulase-negative staphylococci

Obstetrics and gynaecological surgery Gram-negative bacilli, enterococci, anaerobes, group B streptococci

Orthopaedic surgery S. aureus, coagulase-negative staphylococci

Vascular surgery S. aureus, S. epidermidis, gram-negative bacilli


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Flap care

• Many free flap protocols include

warming of the patient and room to

promote peripheral vasodilation and

perfusion.

• Pressure on free flaps should always be

minimized, as excessive pressure may

impede arterial inflow and/ or venous

outflow

• Surgical dressings should be examined

and confirmed to be not excessively

tight.


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• For extremity free flaps, the involved limb

should be elevated to help control edema,

which might otherwise accumulate and

cause pressure on the microvasculature of

the flap.

• Finally, activity restrictions, including weight-

bearing status and range of motion, should

be carefully reviewed, as they may impact

pressure or tension on a free flap.


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• Pedicle flaps: Myocutaneous or osteomyocutaneous flaps based on

a feeding vessel to muscle and perforators to the skin paddle (eg,

flaps based on the pectoralis major, latissimus dorsi, or trapezius)

may be used in a one-stage operation to replace skin, and because

they also contain muscle, they have adequate bulk to repair defects

and may be used to import bone


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Free Flap viability

Capillary Refill

• cutaneous blood is expunged from a small area of the free flap, by

temporarily applying digital pressure, and then pressure is released

to observe the return of blood flow into that area.

• Typically, capillary refill is described in terms of time (normal 2–3

seconds), or whether it is “brisk” versus “delayed.”

• Delayed capillary refill indicates an arterial inflow problem.

• In contrast, excessively brisk capillary refill indicates a venous

outflow problem, as flap tissues become engorged with blood due

to continued arterial inflow.


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Color

• color of the flap skin should exhibit a pink color similar to the site from

which the tissue was transferred

• Pale- problem with the arterial anastomosis resulting in decreased blood

flow into the flap.

• purplish discoloration-this may indicate a problem with the venous

anastomosis, with accumulation of venous blood


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Temperature

• A free flap that is perfusing normally should exhibit a temperature

that is comparable to adjacent nonflap areas of the patient.

• Free flap temperature can be assessed using either an actual

measurement or physical examination, although the latter is

subjective.

• A difference of greater than 1 ° C–3 ° C (1.8 ° F–5.4 ° F) in

temperature between a flap and adjacent nonflap skin may be

indicative of a vascular problem ( Chen et al., 2007 ).


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Turgor

• The balance between vascular inflow and outflow determines tissue

turgor.

• Normally, a free flap should exhibit turgor that is similar to a

patient’s other nonflap tissues.

• If a free flap exhibits diminished turgor, this may herald an arterial

inflow problem.

• Increased prominence of rhytids (wrinkles) on the skin paddle-

arterial inflow problem

• A free flap that is excessively swollen and firm may be experiencing

a venous outflow problem.


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Medical devices

• Acoustic Doppler sonography

• Color duplex ultrasonography

• Flow coupler

• Implantable Doppler

• Laser Doppler flowmetry

• Near-infrared and visible light spectroscopy


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Fluid balance

The three principles of management of fluid balance are:

1. correct any abnormalities

2. provide the daily requirements

3. replace any abnormal and ongoing losses.

• Ideally, any abnormalities will have been identified and corrected

before or during the surgical procedure.

• The normal maintenance fluid requirements will vary depending on

the patient's age, gender, weight and body surface area.


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Basic requirements

• The total body water of an adult comprised 45–60% of the

bodyweight.

• Of the total body water, two-thirds is in the intracellular

compartment and the other one-third is divided between plasma

water (25% of extracellular fluid) and interstitial fluid (75% of

extracellular fluid).


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• The normal daily fluid requirement to maintain a healthy 70-kg adult

is between 2 and 3 L.

• The individual will lose about 1500 mL in the urine and about 500

mL from the skin, lungs and stool.

• Loss from the skin will vary with the ambient temperature.

• The electrolyte composition of intracellular and extracellular fluid

(ECF) varies

• Sodium is the predominant cation in ECF and potassium

predominates in the ICF.

• The normal daily requirements of sodium and potassium are 100-

150 mmol and 60-90 mmol, respectively.


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Replacement

• If an otherwise healthy adult is deprived of the normal daily intake

of fluid and electrolytes, suitable intravenous maintenance must be

provided.

• One relatively simple regimen is 1 L of 0.9% saline and 1–2 L of 5%

dextrose solution.

• Both these solutions are isotonic with respect to plasma.

• The electrolyte solution contains the basic electrolyte requirements

(154 mmol/L of sodium and 154 mmol/L of chloride) and the total

volume can be adjusted with various amounts of dextrose solution.


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• Potassium can be added as required.

• Other solutions (e.g. Ringer's lactate) may contain a more balanced

make-up of electrolytes, but are rarely needed for a patient who is

otherwise well and only requires intravenous fluids for a few days.

• In an adult of average build, maintenance fluids can be restricted to

2 L per day with no potassium supplements until a diuresis has

occurred.


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Maintenance of oral hygiene

1. Normal saline

2. Chlorhexidine is most commonly available as a

0.2 per cent solution.

• However, it has been proven that a 0.12 per cent

solution is just as clinically effective in the

prevention of gingivitis, and reduces the incidence

of side effects.

• Hence it is recommended that a 1:1 dilution with

water be prepared for mouth hygiene use.


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• 3. Povidone iodine-

• It is useful for mucosal infections but does not inhibit plaque

accumulation and should not be used for periods longer than

14 days since a significant amount of iodine is absorbed.

• It is contraindicated as a regular mouth wash in patients with

thyroid disorders or on lithium therapy.

• Side effects include mucosal irritation and hypersensitivity

reactions.


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4. Hydrogen peroxide

• In patients with gross plaque deposits, 3 per cent

hydrogen peroxide solution in a 1:1 dilution with water

may be useful.

• As well as being an effective oxidizing agent against

anaerobic bacteria, it also has a mechanical cleansing

effect due to frothing when in contact with oral debris.

• cleansing established wound dehiscences where debris

accumulation is a concern (due to the effects of gravity).

• Adequate suction is required to remove the froth


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5.Anaesthetic mouth rinses

• These commonly contain either benzocaine cetylpyridinium chloride

or benzydamine hydrochloride, e.g., Difflam which are quaternary

ammonium compound anti-inflammatory agents, in a hydroalcoholic

base.

• Difflam is also available as a chlorhexidine containing solution called

Difflam-C.

• This would be the preferred solution for those patients with mucosal

pain.

• persistent mucositis


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• 6. Listerine contains a combination of phenol-related essential oils,

thymol, eucalyptol, menthol and may also have methylsalicylate in a

hydroalcoholic vehicle, depending on which Listerine product is

being used.

• There have been extensive clinical studies, which demonstrate

reductions in plaque accumulation and gingivitis.

• However, in comparison to chlorhexidine it does not demonstrate

substansivity, is less effective, more expensive and more irritating to

oral tissues.

• Hence, its use in such a patient group is not recommended.


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Suction

• A Yankaur sucker and a flexible suction catheter

is used for removing pooled saliva, blood,

mucous, pus and any other oral secretions.

• This is uncomfortable for the patient and can

predispose to drooling.

• Caution should be used, though, in areas where

free flaps or skin grafts have been placed


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Mobilisation

• Early mobilisation is encouraged.

• The aim of early mobilisation is to encourage good pulmonary

ventilation and to reduce venous stasis.

• For those who cannot mobilise, physiotherapy should be provided to

help with breathing and measures taken to either increase venous

flow (pneumatic calf compression devices) or reduce risks of deep

vein thrombosis (heparin).

• The timing of any planned heparin administration will depend on the

nature of the procedure and the risks of haemorrhage from that

procedure


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Drains and catheters

• Drains may be put down to an operative site or into a wound as it is

being closed to drain collections or potential collections.

• Drains may also be put into the chest cavity to help the lungs re-

expand.

• Drains can act as a point of access for infection, and whilst this may

be of little consequence if the tube has been put in to drain an

abscess cavity, all efforts are made to reduce contamination of any

wound.


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• There is increased use of closed drainage systems and dressings

around drains are changed regularly.

• Any changes to tubes or bags on drains must be carried out using

aseptic techniques.

• Once a drain has served its purpose, it should be removed.

• The longer a drain stays in situ, the greater the risk of infection.

• The contents and volumes discharged through a drain must be

recorded.

• Large volumes, may need the equivalent amount replaced

intravenously.


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Communication

• Most patients will seek some form of reassurance in the immediate

post-operative period.

• How the procedure went and how they are progressing.

• All the tubes, lines and equipment to which they are attached are

quite normal and not an indication of impending disaster.

• Any unexpected finding or complication encountered during the

procedure should be discussed with the patient.

• The timing and detail of this discussion is a matter of fine judgement

and may be best done in the presence of the patient's relatives.


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Nutrition

• Although many factors are involved in assessing overall health status

in patients with cancer, nutrition plays a significant role in

influencing tumor biology, comorbid conditions, and responses to

treatment.

• Clinicians must consider their patients' overall nutritional status

along with any therapeutic interventions being considered, whether

that includes surgery, radiation, chemotherapy, or combinations of

these modalities, to minimize complications and delays in wound

healing in this patient population.


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Nutritional status in patients with cancer

• In most studies assessing weight loss as the primary indicator of

nutritional status in patients with cancer, approximately 40% to 80%

of patients are malnourished, whether this is due to tumor biology,

surgical procedures, radiation or chemotherapy, or psychological

factors.

• Malnourished patients have a greater susceptibility to infectious

complications along with delayed wound healing, which, in

combination with their diseased state, significantly increases

postoperative morbidity and mortality.


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• Malnutrition also increases the metabolic activity of organs such as

the liver, which physiologically borrows substrate from skin and

muscle to maintain vital functions

• Maintaining adequate nutritional balance in cancer patients

undergoing treatment is essential to minimize the risk of

complications such as enteric fistula formation, incisional wound

dehiscence, as well as carotid rupture after head and neck surgery.


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• Physiologic stressors such as infection and injury initiate a series of

metabolic reactions leading to a negative nitrogen balance and

ultimately a decrease in lean body mass.

• Malnutrition has detrimental effects on cellular and humoral

immunity in addition to negatively influencing tissue function and

repair.

• Malnourished cancer patients have less tolerance for therapeutic

interventions than patients in better nutritional states.


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• A minimum requirement of 25 to 30 kJ/kg per day is initially

recommended for critically ill patients.

• Carbohydrates tend to be the primary source of nonprotein calories

during the hypermetabolic state and can comprise 60% to 70% of

the daily nutritional requirements.

• Daily fat requirements account for the additional 25% to 30% of

nonprotein calories in hypermetabolic patients.

• Fat provides not only essential dietary fatty acids but also an energy-

rich substrate to help meet metabolic demands.


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• Amino acids should be provided in adequate amounts to restore the

nitrogen balance and limit muscle breakdown.

• In general, protein requirements in septic or injured patients range

from 1.2 to 2.0 g/kg per /day, depending on the extent of injury and

degree of physiologic stress.

• Typically, the suggested nonprotein calorie to nitrogen ratio is

approximately 50:1

• in cancer patients, higher levels of stress require increased protein

needs in the range of 80:1 to 100:1.


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Enteral and parenteral nutritional support

• The general rule of thumb for postoperative nutrition favors enteral

access: “If the gut works, use it.”

• Enteral feeding is easily administered, well-tolerated, helps maintain

the barrier mechanism of the gastrointestinal tract, and promotes

mucosal growth and development.

• Enteral nutrition is more efficient, less expensive, and is associated

with fewer metabolic complications like hyperglycemia, cholestasis,

and fatty infiltration of the liver, all of which occur more frequently

when the parenteral route is utilized.


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Nutritional components for wound healing

• water-soluble and fat-soluble vitamins function as cofactors in many

processes involved in wound repair and healing.

• Vitamins C and A, along with several other essential components,

contribute to optimize wound healing and recovery.

• It is critical to administer vitamin C in critically ill or injured patients,

as deficiency can rapidly develop because of minimal vitamin C

stores in the body.

• Patients at risk of developing vitamin C deficiency should receive 1

to 2 g of vitamin C daily to optimize wound healing


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• Higher tissue concentrations of vitamin A increases recruitment of

macrophages into wounds, leading to more effective phagocytic

activity and cell-mediated immunity.

• Vitamin A deficiency leads to decreased collagen synthesis and

cross-linking, decreased epithelialization, and slower rate of wound

closure.

• Patients with severe injuries, malabsorption, or malnutrition are at

risk of vitamin A deficiency and should receive dietary supplement

of 25,000 IU/day of vitamin A.


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• Although the contributions of vitamin E are not clearly defined, it is

likely that it contributes toward the wound healing process.

• Zinc deficiency leads to decreased DNA and RNA synthesis, impaired

protein production, and decreased cell proliferation:

• in zinc-deficient animals, wound granulation tissue contains lower

concentrations of collagen and noncollagenous proteins.

• As with vitamin C, zinc supplementation has no therapeutic value

unless a true zinc deficiency exists


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Deep vein thrombosis

• Presentation may be silent (60%) or as a clinical syndrome (40%)

with calf pain and tenderness, oedema of the leg and/or pain on

dorsiflexion of the foot (Homan's sign).

• Ultrasonography and duplex scanning with Doppler ultrasound have

a sensitivity and specificity greater than 90%.


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• heparin i.v. in a dose of 20,000-30,000 units per day.

• APTT is kept at 1.5-2.5 times the control value.

• Heparin therapy is continued for 5-7 days and is replaced by oral

vitamin K antagonists such as warfarin.

• The dose of warfarin is adjusted according to the thromboplastin

time with reference to an international standard (INR).

• Heparin is discontinued when full anticoagulation has been achieved

and the warfarin is continued for 3-6 months to minimise the risk of

further thrombosis and the development of complications


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Hospital acquired infections

• Hospital-acquired infections are caused by viral, bacterial, and fungal

pathogens; the most common types are bloodstream infection (BSI),

pneumonia (eg, ventilator-associated pneumonia [VAP]), urinary

tract infection (UTI), and surgical site infection (SSI).

• Cancer patients have a higher risk of severe sepsis in comparison

with non-cancer patients, with an increased risk for hospital-

acquired infections (HAI), particularly with multidrug resistant

bacteria (MDRB). The aim of the study is to describe the frequency

and characteristics of HAI and MDRB in critically ill cancer patients


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• Cancer patients have a 3- to 5-fold greater risk of severe sepsis in

comparison with non-cancer patients, with an increased risk for HAI,

particularly with multidrug resistant bacteria, which are associated

with increased therapeutic failure and high mortality rates.

• Patients with neutropenia or hematological malignancies appear to

be particularly vulnerable to this situation, compared with patients

with solid tumors


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Risk factors for hospital-acquired infection in cancer patients in a central Chinese hospital- Xia Zhao et al; 2016


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References

• Post operative care of oral and maxillofacial surgery patients- Ogle et

al- oral and maxillofacial clinics of north America; 2006

• Oral cancer pain- dios et al; journal of oral oncology- 2010

• Post operative fluid management- kayiliogu et al; world journal of

critical care medicine; 2015

• Risk factors for hospital-acquired infection in cancer patients in a

central Chinese hospital- Xia Zhao et al; 2016

• Maintenance of mouth hygiene in patients with oral cancer in the

immediate post-operative period -A Chandu; Australian Dental

Journal 2002


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• Post-Operative Drop in Hemoglobin and Need of Blood Transfusion

in Cesarean Section at Dhulikhel Hospital, Kathmandu University

Hospital- Singh; kathmandu university medical journal; 2013

• Transfuse or Not to Transfuse: For Post-op Anemia - Jasmine Chao-

American Journal of Clinical Medicine; 2011

• Current Approaches to Free Flap Monitoring – Chao et al.

• Oral Cancer Malnutrition Impacts Weight and Quality of Life -Nils-

Claudius Gellrich

• Oral cancer in India: An epidemiologic and clinical review - R.

Sankaranarayanan, oral surc oral med oral pathol 1990


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Thank you

postoperative cancer care

Health & Medicine