Free Flap - Admission protocol

General guidelines 

• Admission Order Set: Microvascular Free Flap PostOp Orders are in EPIC. 

• Day of surgery

  • If you are on call the night of a free-flap, you are expected to join the surgery once you are available and assist the resident who has been in the case during the day and write the admission orders. 

  • All free flap patients require a post-op "flap check" at the half-way point between time of OR completion and time of AM rounds by the person on call that night (example: if the case ends at 5 PM and morning rounds is at 7 AM, a post-op check should be performed at Midnight). Make sure to visualize flap bleeding/doppler signal in OR with attending/chief before leaving.

• Flap check standard physical examination points

  • Doppler check to anastomosed vessels (marked on the skin with suture)

  • Scratch test to cutaneous portion of free-flap (if present)

  • Flap turgor and warmth

  • Capillary re-fill (depending on donor site)

  • Drain output over last 8 and 24 hours

  • Neurovascular check for donor sites 

• The first flap check should also include a full evaluation of the patient 

  • • Rediscuss the patient with nursing and consulting staff as well as the ICU MDs 

    • Ask the patient's subjective assessment, if awake enough

    • Complete a basic neurological exam, always in mind the possibility of stroke 

    • Check basic things like the SCDs, etc. 

• Arterial line should be removed as soon as judiciously possible, usually POD 1

• Foley catheter should be removed as soon as judiciously possible, usually POD 1

• Tracheostomy cuff can be let down on POD 1. make sure to suction the trach after doing this.

• Tube feeds started on POD 1 (or night of surgery) starting with low rate of continuous feeds which is gradually increased to goal rate then converted to bolus feeds

  • Adjust the tube feed orders according to the Dietitian's recommendations 

• Trach tube first changed generally at POD 3-5, may be delayed for a more difficulty airway

• Laryngectomy HME changed daily or more as needed 

• Laryngectomy tube cleaned every day or more as needed

  • The second laryngectomy tube should be obtained in the operating room for the patient to be discharged with 

• Arm and leg casts (for RFFF and FFF) are removed on day of discharge. Photodocument the wound and wrap as appropriate. (skin graft should have Vaseline, xeroform, kerlix wrap)

Positioning

• The patient should have the head midline or slightly to one side depending on anastomosis

• Avoid trach ties or any circumferential neck ties of any sort (trachs should be sutured) during hospital stay

• Elevate the donor limb.

• Elevate head of bed

Neuro

• Tylenol 1000 mg /Ibuprofen 600 mg ATC 

• Moderate pain prn: Oxycodone 5 mg PRN

• Severe  pain prn: Oxycodone 10 mg; Dilaudid 0.4 mg IV

CV

• Avoid pressors (and nicotine patches if possible)

• MAP > 60

Pulm

• RT order - clarify humidification and suctioning needs 

• Print and post critical airway sign over the head of bed

• If laryngectomy stoma, educate patient / patient caregiver, RN, RT, and ICU MD re HME 

  • Change HME daily or more as needed

  • Clean laryngectomy tube every other day or more as needed

• POD 1 - deflate tracheostomy tube cuff 

Hem/ID

• 24-48 hrs intravenous antibiotics for operations that violate the aerodigestive tract 

• Unasyn for all patients who are not penicillin allergic 

  • Clindamycin for penicillin allergic patients 

FEN

• POD 0 - Order CXR to check NGT placement in stomach

  • Once confirmed, order allowing NGT use

• Order Dietary consult - clarify nutritional and tube feeds needs 

• POD 1 AM - Order "trickle feeds," usually Isosource 1.5, may start at 30 ml/hour and advance as tolerated to goal

• Dr. Fong additional nutritional supplement

  • IMPACT

    • Order until nutrition supplement, drop down list, IMPACT

    • 3x/day 

• Note: Nutrition is critical to the patient's overall well being and surgical recovery

  • If note already completed, check the following labs

    • TSH, prealbumin, albumin 

    • Multiple factors stand against optimizing your patient's nutrition

    • 2009: A descriptive review of the factors contributing to nutritional compromise in patients with head and neck cancer

PPX

• POD 1

  • Start Lovenox or Heparin POD 1 

  • Start ASA 325 mg, stop upon discharge 

  • Remove foley 

• Incentive spirometry 

• Sequential compression devices

• Physical activity

Lines

• POD 1

  • Remove foley, if possible

  • Remove A-line, if possible

• Maintain NGT until cleared by surgeon and Speech Therapy for oral intake 

Wound

• STSG donor site dressing options:

  • Tegaderm

    • Remove Tegaderm POD 3 or when it starts leaking and leave open to air until dry

    • Then, apply thin layer of Vaseline over wound daily and leave open to air otherwise 

  • Xeroform with corners sutures using 2-0 Silk (keep open to air until dry) vs

  • Mepilex, Xeroform, Telfa, ABD pad

• Keep donor extremity elevated

• Remove casts and bolster dressing from skin graft at first post-op clinic visit

  • Association of Bolster Duration With Uptake Rates of Fibula Donor Site Skin Grafts. 

  • If skin graft present, leave Mepilex in place; Replace Xeroform, Telfa, Kerlix wrap

• Drains should stay in at least 5 days unless told otherwise

• Head midline or away from pedicle site (post sign) 

• Activity order 

  • Fibula: NWB for 5 days, toe touch 5 days, partial weight bearing 5 days, full weight bearing 5 days

  • Forearm: NWB for 5 days, partial weight bearing 5 days

Signs

• Head positioning - "Please keep head midline or to *** side" 

  • In general, avoid turning head toward the side of anastomosis

• Critical airway 

  • For tracheostomy post sign found here

  • For total laryngectomy post sign found here

Consults/Disposition planning

• RT

• Dietician

• PT - clarify PT and wound activity needs 

• PCC - Determine disposition: SNF vs home vs other; Determine need for 

  • Social work 

  • Home health

• Recuperative skills

  • trach care, tube feeds, possible wound care

• Speech Therapy upon discharge

  • Coordinate joint follow up appointment with surgeon in clinic 

  • Arrange at least 30 minutes for this appointment 

  • Contact both the surgeon and ST via staff message 

• DME and home health

  • Most free-flap patients will need home health and DME (equipment) forms filled and signed by an attending

    • These are sent electronically by the patient care coordinator (PCC) to the attending and they will communicate this with you about this to remind attendings to sign

  • Not having these ready can lead to delay in discharge