Summary
The COVID-19 pandemic has had significant implications for citizens globally and for the healthcare system, including plastic surgeons. Operations of the upper aerodigestive tract, including head and neck reconstruction and craniomaxillofacial procedures, are of particularly high risk because they may aerosolize the virus and lead to severe surgeon and surgical team illness. Until the virus is eradicated or widespread vaccination occurs, we recommend certain precautions to safely perform these operations. We propose evolving algorithms for head and neck reconstruction and facial trauma surgeries to maintain provider safety. Central to these guidelines are preoperative COVID-19 testing, appropriate personal protective equipment, and operative techniques/principles that minimize operative time and aerosolization of the virus. We aim to provide efficient care to our patients throughout this pandemic, while maintaining the safety of plastic surgeons and other healthcare providers.
Aim: Negative pressure wound therapy (NPWT) has been studied extensively in adult patients, but less is known about pediatric patients. This study assesses the efficacy and safety of vacuumassisted closure ® usage in pediatric oncology patients. Methods: Retrospective data on all patients treated with NPWT at a single pediatric oncology hospital were collected between April 2005 and September 2013. Details on pre-treatment factors, treatment course, and post-treatment events were collected. No control group was available for comparison. Results: Sixty-six patients were identified, with a total of 74 wounds. Median age at the time of NPWT application was 13 years (range, 10 months-23 years). Median duration of treatment was 21 days (range, 3-236 days). NPWT therapy was started with continuous high negative pressures (125 mmHg) in most patients. Sixty-nine percent of patients had their wounds healed without intervention, and 20% of patients required surgical closure. NPWT was discontinued temporarily secondary to skin maceration or cellulitis in 12% of patients. NPWT was used in a number of non-standard clinical situations, including primarily-closed incisional wound NPWT and bridging NPWT through adjuvant chemotherapy. Conclusion: In pediatric oncology patients, NPWT is safe, effective, and well-tolerated. Although this study is retrospective in nature, and there was no control group for comparison, these data are important for clinicians to guide therapy as device monitoring agencies and payors increasingly require outcomes data for the approval of therapeutic decisions.
The COVID-19 pandemic has presented new challenges to microsurgeons. The virus is highly transmissible, with increased risk during operations that involve the aerodigestive tract. It is important to be able to identify high-risk operations and scenarios to guide management decisions and selection of personal protective equipment. Preoperative testing is a key element in identifying high-risk scenarios, and preoperative testing protocols are essential to maintaining safety in the COVID-19 era. Because COVID-19 can be transmitted via the conjunctiva, adaptations to loupes and microscopes are necessary to safely perform microsurgery in high-risk scenarios. We outline a potential risk stratification algorithm, as well as precautions for each scenario. Potential areas for innovation are also discussed.
Background:
Enhanced recovery after surgery (ERAS) programs have been detailed in the literature predominantly in the inpatient setting. The purpose of this study was to determine the effect of an ERAS protocol with a preoperative educational class on opioid prescribing and patient outcomes for outpatient breast surgery.
Methods:
An ERAS protocol was formulated focusing on preoperative education, multimodal pain control, and an intraoperative block. The study was conducted as an institutional review board–approved retrospective review. Women undergoing breast reconstruction revision, breast reduction, delayed insertion of prosthesis, tissue expander to implant exchange, and matching procedures were included. The patients were separated into pre-ERAS and ERAS cohorts. Data on demographic characteristics, postanesthesia care unit (PACU) length of stay, PACU oral morphine equivalent (OME) consumption, outpatient OME prescriptions, major and minor complications, and need for additional opioid prescriptions were collected. Analysis was performed with the Fisher exact test or chi-square test as appropriate.
Results:
Group 1 (pre-ERAS) and group 2 (ERAS) each included 68 patients. The cohorts had similar age, body mass index, diabetes status, and tobacco use. Group 1 was prescribed an average of 216 OMEs, compared with 126.4 OMEs for group 2, a 41.5% decrease (P < 0.0001). The pre-ERAS group consumed an average of 23.3 OMEs in the PACU versus 16.6 OMEs in the ERAS group (P = 0.005). Fewer patients in the ERAS group required additional prescriptions for narcotic pain medication at postoperative follow-up (P = 0.116). No differences were seen in major or minor complications.
Conclusion:
An ERAS protocol that uses a multimodal approach to pain control and preoperative patient education is useful in the outpatient setting and can help decrease opioid consumption.
CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, III.
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