Incorporating mesh into rectus fascia repair in free and muscle-sparing free TRAM flap cases significantly reduces the rate of postoperative abdominal complications to levels equivalent to those for DIEP flap reconstructions. The authors advocate deciding intraoperatively between DIEP and muscle-sparing free TRAM flap dissections based on ease of dissection and whichever offers optimal safety and flap perfusion. Routine use of mesh in donor-site repair will decrease postoperative abdominal morbidity in unilateral and bilateral cases.

The routine use of a single-injection, transverse, in-plane ultrasound-guided technique for TPVB in patients undergoing mastectomy with immediate breast reconstruction is associated with very few complications.

Background: The allocation of intensive care unit (ICU) beds for postoperative patients is a challenging daily task that could be assisted by the real-time detection of ICU needs. The goal of this study was to develop and validate an intraoperative predictive model for unplanned postoperative ICU use. Methods: With the use of anesthesia information management system, postanesthesia care unit, and scheduling data, a data set was derived from adult in-patient noncardiac surgeries. Unplanned ICU admissions were identified (4,847 of 71,996; 6.7%), and a logistic regression model was developed for predicting unplanned ICU admission. The model performance was tested using bootstrap validation and compared with the Surgical Apgar Score using area under the curve for the receiver operating characteristic. Results: The logistic regression model included 16 variables: age, American Society of Anesthesiologists physical status, emergency case, surgical service, and 12 intraoperative variables. The area under the curve was 0.905 (95% CI, 0.900–0.909). The bootstrap validation model area under the curves were 0.513 at booking, 0.688 at 3 h before case end, 0.738 at 2 h, 0.791 at 1 h, and 0.809 at case end. The Surgical Apgar Score area under the curve was 0.692. Unplanned ICU admissions had more ICU-free days than planned ICU admissions (5 vs. 4; P < 0.001) and similar mortality (5.6 vs. 6.0%; P = 0.248). Conclusions: The authors have developed and internally validated an intraoperative predictive model for unplanned postoperative ICU use. Incorporation of this model into a real-time data sniffer may improve the process of allocating ICU beds for postoperative patients.

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The majority of the variation was not described by the models, possibly indicating high per-case random variation. The largest sources of variation identified by our models included attending anesthesiologist, procedure type, and case duration. The difference in cost between institutions was statistically significant but was minor. While many prior studies have found significant savings resulting from cost-reducing interventions, our findings suggest that because the overall cost of anesthetic drugs was small, the savings resulting from interventions focused on the clinical practice of attending anesthesiologists may be negligible, especially in institutions where access to more expensive drugs is already limited. Thus, cost-saving efforts may be better focused elsewhere.