Complications of microsurgical reconstruction of obstetrical brachial plexus palsy.

The charts of the 173 consecutive patients who underwent microsurgical reconstruction for obstetrical brachial plexus palsy from 1988 to 1999 (inclusive) in the Division of Plastic Surgery at the Hospital for Sick Children were analyzed. The overall complication rate was 33.5 percent, and there was no mortality in this series. The most significant intraoperative complication was accidental extubation, which occurred five times in the first 84 patients (6 percent of this early group; 2.9 percent of the whole series). This complication was addressed by suturing the endotracheal tube to the membranous septum and by using a transparent drape to allow direct visualization of the tube in all 89 subsequent patients. There have been no further accidental extubations. Postoperative fluid overload occurred in 14 patients (8.1 percent), three (1.7 percent) of whom developed pulmonary edema. Intensive care unit admission was required in two of those patients. Diuretic treatment was required in seven patients. No patient receiving less than or equal to 4 ml/kg/hour developed fluid overload, whereas 50 percent of the patients receiving greater than or equal to 10 ml/kg/hour did. Currently, the authors' policy is to strictly limit intravenous maintenance fluids to 4 ml/kg/hour or less. Despite the long and complex procedure required to reconstruct obstetrical brachial plexus palsy, the incidence of significant complications can be minimized with simple precautions, such as suturing the endotracheal tube to the septum or reducing the amount of fluids administered during the operation.