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J Reconstr Microsurg 2013; 29(07): 473-480
DOI: 10.1055/s-0033-1345434
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Analysis of Free Flap Complications and Utilization of Intensive Care Unit Monitoring

Agustin Cornejo
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
,
Sirinivas Ivatury
2   Division of Trauma and Surgical Critical Care, Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
,
Curtis N. Crane
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
,
John G. Myers
2   Division of Trauma and Surgical Critical Care, Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
,
Howard T. Wang
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
› Author Affiliations
Further Information

Publication History

03 December 2012

03 February 2013

Publication Date:
09 May 2013 (online)

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Abstract

We aimed to determine the optimal time for intensive care unit (ICU) monitoring after free flap reconstruction based on the timing of surgical complications. We reviewed retrospectively 179 free flaps in 170 subjects during an 8-year period at University Hospital. Thirty-seven flaps were reoperated due to vascular (n = 16, 8.9%) and nonvascular complications (n = 21, 11.7%). Vascular complications presented earlier relative to nonvascular complications (10.8 versus 99.3 hours). The flap survival rate was 93.2% with a mean ICU length of stay of 6.2 days. The lack of standardized monitoring protocols can lead to overutilization of ICU. Sometimes, flap monitoring is not the limiting factor, as patients with other comorbidities necessitate longer ICU stays. However, our study suggests that close monitoring of flaps seems most critical during the first 24 to 48 hours, when most thrombotic complications occur and prompt identification and re-exploration is critical. Some thrombosis and most hematomas present within 72 hours, and thus close monitoring is still warranted. We suggest close monitoring of free flaps in the ICU or dedicated flap monitoring unit where nursing can check the flap on an every-1-to-2-hour basis for the first 72 hours postoperatively to assure optimal surveillance of any potential problems.

Keywords

free flap monitoring - free flap complications - intensive care unit utilization
 

  • References

  • 1 Jones NF, Jarrahy R, Song JI, Kaufman MR, Markowitz B. Postoperative medical complications—not microsurgical complications—negatively influence the morbidity, mortality, and true costs after microsurgical reconstruction for head and neck cancer. Plast Reconstr Surg 2007; 119 (7) 2053-2060
    CrossrefPubMedGoogle Scholar
  • 2 Spiegel JH, Polat JK. Microvascular flap reconstruction by otolaryngologists: prevalence, postoperative care, and monitoring techniques. Laryngoscope 2007; 117 (3) 485-490
    CrossrefPubMedGoogle Scholar
  • 3 Marsh M, Elliott S, Anand R, Brennan PA. Early postoperative care for free flap head & neck reconstructive surgery—a national survey of practice. Br J Oral Maxillofac Surg 2009; 47 (3) 182-185
    CrossrefPubMedGoogle Scholar
  • 4 Abdel-Galil K, Mitchell D. Postoperative monitoring of microsurgical free-tissue transfers for head and neck reconstruction: a systematic review of current techniques—part II. Invasive techniques. Br J Oral Maxillofac Surg 2009; 47 (6) 438-442
    CrossrefPubMedGoogle Scholar
  • 5 Talesnik A, Markowitz B, Calcaterra T, Ahn C, Shaw W. Cost and outcome of osteocutaneous free-tissue transfer versus pedicled soft-tissue reconstruction for composite mandibular defects. Plast Reconstr Surg 1996; 97 (6) 1167-1178
    CrossrefPubMedGoogle Scholar
  • 6 Haddock NT, Gobble RM, Levine JP. More consistent postoperative care and monitoring can reduce costs following microvascular free flap reconstruction. J Reconstr Microsurg 2010; 26 (7) 435-439
    Article in Thieme ConnectPubMedGoogle Scholar
  • 7 Chen KT, Mardini S, Chuang DC , et al. Timing of presentation of the first signs of vascular compromise dictates the salvage outcome of free flap transfers. Plast Reconstr Surg 2007; 120 (1) 187-195
    CrossrefPubMedGoogle Scholar
  • 8 Bakri K, Moran SL. Monitoring for upper-extremity free flaps and replantations. J Hand Surg Am 2008; 33 (10) 1905-1908
    CrossrefPubMedGoogle Scholar
  • 9 Barnato AE, Kahn JM, Rubenfeld GD , et al. Prioritizing the organization and management of intensive care services in the United States: the PrOMIS Conference. Crit Care Med 2007; 35 (4) 1003-1011
    CrossrefPubMedGoogle Scholar
  • 10 Halpern NA, Pastores SM. Critical care medicine in the United States 2000-2005: an analysis of bed numbers, occupancy rates, payer mix, and costs. Crit Care Med 2010; 38 (1) 65-71
    CrossrefPubMedGoogle Scholar
  • 11 Truog RD, Brock DW, Cook DJ , et al; Task Force on Values, Ethics, and Rationing in Critical Care (VERICC). Rationing in the intensive care unit. Crit Care Med 2006; 34 (4) 958-963 , quiz 971
    CrossrefPubMedGoogle Scholar
  • 12 Keller A. A new diagnostic algorithm for early prediction of vascular compromise in 208 microsurgical flaps using tissue oxygen saturation measurements. Ann Plast Surg 2009; 62 (5) 538-543
    CrossrefPubMedGoogle Scholar
  • 13 Smit JM, Acosta R, Zeebregts CJ, Liss AG, Anniko M, Hartman EH. Early reintervention of compromised free flaps improves success rate. Microsurgery 2007; 27 (7) 612-616
    CrossrefPubMedGoogle Scholar
  • 14 Bradley PJ. Should all head and neck cancer patients be nursed in intensive therapy units following major surgery?. Curr Opin Otolaryngol Head Neck Surg 2007; 15 (2) 63-67
    CrossrefPubMedGoogle Scholar
  • 15 Cornejo A, Rodriguez T, Steigelman M , et al. The use of visible light spectroscopy to measure tissue oxygenation in free flap reconstruction. J Reconstr Microsurg 2011; 27 (7) 397-402
    Article in Thieme ConnectPubMedGoogle Scholar
  • 16 Guillemaud JP, Seikaly H, Cote D, Allen H, Harris JR. The implantable Cook-Swartz Doppler probe for postoperative monitoring in head and neck free flap reconstruction. Arch Otolaryngol Head Neck Surg 2008; 134 (7) 729-734
    CrossrefPubMedGoogle Scholar
  • 17 Rozen WM, Chubb D, Whitaker IS, Acosta R. The efficacy of postoperative monitoring: a single surgeon comparison of clinical monitoring and the implantable Doppler probe in 547 consecutive free flaps. Microsurgery 2010; 30 (2) 105-110
    PubMedGoogle Scholar
  • 18 Chubb DP, Rozen WM, Whitaker IS, Ashton MW. Postoperative monitoring of microsurgical free tissue transfers for head and neck reconstruction: a systematic review of current techniques. Br J Oral Maxillofac Surg 2009; 47 (7) 574-575
    CrossrefPubMedGoogle Scholar
  • 19 Chernichenko N, Ross DA, Shin J, Sasaki CT, Ariyan S. End-to-side venous anastomosis with an anastomotic coupling device for microvascular free-tissue transfer in head and neck reconstruction. Laryngoscope 2008; 118 (12) 2146-2150
    CrossrefPubMedGoogle Scholar
  • 20 Yap LH, Constantinides J, Butler CE. Venous thrombosis in coupled versus sutured microvascular anastomoses. Ann Plast Surg 2006; 57 (6) 666-669
    CrossrefPubMedGoogle Scholar
  • 21 Zhong T, Neinstein R, Massey C , et al. Intravenous fluid infusion rate in microsurgical breast reconstruction: important lessons learned from 354 free flaps. Plast Reconstr Surg 2011; 128 (6) 1153-1160
    CrossrefPubMedGoogle Scholar
  • 22 Monroe MM, McClelland J, Swide C, Wax MK. Vasopressor use in free tissue transfer surgery. Otolaryngol Head Neck Surg 2010; 142 (2) 169-173
    CrossrefPubMedGoogle Scholar
  • 23 Appleton SE, Ngan A, Kent B, Morris SF. Risk factors influencing transfusion rates in DIEP flap breast reconstruction. Plast Reconstr Surg 2011; 127 (5) 1773-1782
    PubMedGoogle Scholar
  • 24 Bower WF, Jin L, Underwood MJ, Lam YH, Lai PB. Perioperative blood transfusion increases length of hospital stay and number of postoperative complications in noncardiac surgical patients. Hong Kong Med J 2010; 16 (2) 116-120
    PubMedGoogle Scholar
  • 25 D'Ayala M, Huzar T, Briggs W , et al. Blood transfusion and its effect on the clinical outcomes of patients undergoing major lower extremity amputation. Ann Vasc Surg 2010; 24 (4) 468-473
    CrossrefPubMedGoogle Scholar