Yu Phoebe K, Sethi Rosh K V, Rathi Vinay, Puram Sidharth V, Lin Derrick T, Emerick Kevin S, Durand Marlene L, Deschler Daniel G
Department of Otolaryngology Massachusetts Eye and Ear Infirmary Boston Massachusetts.
Department of Otolaryngology Harvard Medical School Boston Massachusetts.
Laryngoscope Investig Otolaryngol. 2018 Nov 28;4(1):39-42. doi: 10.1002/lio2.221. eCollection 2019 Feb.
The need for intensive care unit (ICU) admission and mechanical ventilation after head and neck microvascular free flap reconstructive surgery remains controversial. Our institution has maintained a longstanding practice of immediately taking patients off mechanical ventilation with subsequent transfer to intermediate, non-ICU level of care with specialized otolaryngologic nursing. Our objective was to describe postoperative outcomes for a large cohort of patients undergoing this protocol and to examine the need for routine ICU transfer.
We performed a retrospective review of 512 consecutive free flaps treated with a standard protocol of immediate postoperative transfer to an intermediate-level care unit with specialized otolaryngology nursing. Outcome measures included ICU transfer, ventilator requirement, flap failure, postoperative complications, and length of stay. Predictors of ICU transfer were identified by multivariable logistic regression.
The vast majority of patients did not require intensive care. Only a small fraction (n = 18 patients, 3.5%) subsequently transferred to the ICU, most commonly for respiratory distress, cardiac events, and infection. The most common complications were delirium/agitation (n = 55; 10.7%) and pneumonia (n = 51; 10.0%). Sixty-five cases (12.7%) returned to the OR, most commonly for hematoma/bleeding (n = 41; 8.0%) and anastomosis revision (n = 20; 3.9%). Heavy alcohol consumption and greater number of medical comorbidities were significant predictors of subsequent ICU transfer.
Among head and neck free flap patients, routine cessation of mechanical ventilation and transfer to intermediate-level care with specialized ENT nursing was found to be safe with infrequent subsequent ICU transfer and low complication rates. Routine transfer to intermediate-level care in this population may prevent unnecessary ICU utilization and facilitate the delivery of high-value, disease-centered care.
3b.
头颈部微血管游离皮瓣重建手术后入住重症监护病房（ICU）及机械通气的必要性仍存在争议。我院长期以来一直实行术后立即撤掉患者的机械通气，随后将其转至中级、非ICU级别的护理病房，并配备专业的耳鼻喉科护理人员。我们的目的是描述一大群接受该方案治疗的患者的术后结局，并探讨常规转入ICU的必要性。
我们对512例连续接受游离皮瓣手术的患者进行了回顾性研究，这些患者均按照术后立即转至配备专业耳鼻喉科护理的中级护理病房的标准方案进行治疗。结局指标包括转入ICU情况、呼吸机需求、皮瓣失败、术后并发症及住院时间。通过多变量逻辑回归确定转入ICU的预测因素。
绝大多数患者不需要重症监护。只有一小部分（n = 18例患者，3.5%）随后转入ICU，最常见的原因是呼吸窘迫、心脏事件和感染。最常见的并发症是谵妄/躁动（n = 55例；10.7%）和肺炎（n = 51例；10.0%）。65例（12.7%）患者返回手术室，最常见的原因是血肿/出血（n = 41例；8.0%）和吻合口修复（n = 20例；3.9%）。大量饮酒和更多的内科合并症是随后转入ICU的显著预测因素。
在头颈部游离皮瓣患者中，发现术后常规停止机械通气并转至配备专业耳鼻喉科护理的中级护理病房是安全的，随后转入ICU的情况很少，并发症发生率低。对该人群常规转至中级护理病房可避免不必要的ICU使用，并有助于提供高价值、以疾病为中心的护理。
3b
