Postoperative Free Flap Breast Protocol Optimizing Resources and Patient Safety

Abstract

Background As deep inferior epigastric artery perforator (DIEP) flaps have gained popularity in breast reconstruction, the postoperative care of these patients, including the appropriate hospital length-of-stay and the need for intensive care unit (ICU) admission, has become a topic of debate. At our institution, we have adopted a pathway that aims for discharge on postoperative day 3, utilizing continuous tissue oximetry without ICU admission. This study aims to evaluate outcomes with this pathway to assess its safety and feasibility in clinical practice. Methods A retrospective review was performed of patients undergoing DIEP flap breast reconstruction between January 2013 and August 2014. Data of interest included patient demographics and medical history as well as complication rates and date of hospital discharge. Results In total, 153 patients were identified undergoing 239 DIEP flaps. The mean age was 50 years (standard deviation [SD] = 10.2) and body mass index (BMI) 29.4 kg/m2 (SD = 5.2). Over the study period, the flap failure rate was 1.3% and reoperation rate 3.9%. Seventy-one percent of patients were discharged on postoperative day 3. Nine patients required hospitalization beyond 5 days. Theoretical cost savings from avoiding ICU admissions were $1,053 per patient. Conclusion A pathway aiming for hospital discharge on postoperative day 3 without ICU admission following DIEP flap breast reconstruction can be feasibly implemented with an acceptable reoperation and flap failure rate.

The False Positive Rate of Transcutaneous Tissue Oximetry Alarms in Microvascular Breast Reconstruction Rises after 24 Hours

“…17,18 However, overall health care savings have been demonstrated when the tissue oximetry use permits for flap monitoring on the ward rather than the ICU. 3,5,14 Our findings show false positive alarms as an additional disadvantage of transcutaneous tissue oximetry monitoring. Causes of erroneous readings include poor signal quality due to overhead operating room lights, initial probe position directly over a vessel that will give saturation readings that are not representative of flap perfusion, and a falsely elevated initial reading while the patient is still intubated and under general anesthesia.…”

“…3 Other investigators have shown benefits of incorporating tissue oximetry in flap monitoring protocols as well. [14][15][16] Although the literature demonstrates benefits of transcutaneous tissue oximetry monitoring, the primary disadvantage is cost. The disposable sensor probes average $1,000 each with consoles costing about $30,000.…”

Do Patient Expectations of Discharge Affect Length of Stay after Deep Inferior Epigastric Perforator Flap for Breast Reconstruction?

“…ERAS protocols have demonstrated ability to standardize postoperative stays and facilitate discharge. [12][13][14][15][16][17] Our study has exhibited the influence of patient expectation of discharge. We have shown that setting an expectation of a particular early discharge date can significantly affect the LOS.…”

“…The implementation of enhanced recovery after surgery (ERAS) protocols has improved postoperative pain, minimized narcotics, and reduced LOS without increasing postoperative adverse effects. [12][13][14][15][16][17] The literature also shows that transversus abdominis plane (TAP) blocks reduce the level of narcotics that patients require to control their pain after abdominally based breast reconstruction. 18,19 Goals of DIEP flap postoperative protocols include enhanced patient outcomes, improved pain control with minimizing narcotics, and controlling costs with decreasing LOS.…”

Nursing Monitoring of Microsurgical Free Flaps: Identifying and Addressing Knowledge Gaps

“…2,3 They concluded that bypassing the ICU and opting for immediate floor level care with continuous tissue oximetry achieves reduced hospital cost, improved access to ICU beds, and has an acceptable rate of flap failure. 21 Similarly, in a study by Carruthers et al, no patients were admitted to the ICU postoperatively. Instead, they underwent hourly flap checks for the first 12 hours, transitioning to every 4 hours after that, with continuous tissue oximetry until discharge.…”