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Early postoperative care for free flap head & neck reconstructive surgery - a national survey of practice
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British Journal of Oral and Maxillofacial Surgery 47 (2009) 182–185
Early postoperative care for free flap head & neck reconstructive surgery - a national survey of practice M. Marsh a , S. Elliott a,∗ , R. Anand b , P.A. Brennan b a b
Department of Anaesthetics, Queen Alexandra Hospital, Portsmouth, PO6 3LY, United Kingdom Department of Maxillofacial Surgery, Queen Alexandra Hospital, Portsmouth, PO6 3LY, United Kingdom
Accepted 8 June 2008 Available online 21 July 2008
Abstract There is considerable variation in the post-operative management of head and neck free flaps in the UK. We undertook a national postal survey of maxillofacial surgical units in the UK who perform free flap reconstruction following ablative head and neck surgery. Questions were asked about the routine postoperative care of a hypothetical, straightforward patient undergoing free flap reconstruction to determine whether there were any trends in managing these patients. There was considerable variation in the number of free flaps performed by each unit per year. The majority of patients (87%) are managed in either an intensive care or high dependency unit. The routine use of a tracheostomy is common (69%). There was also variation in the management of these cases, particularly with the requirement for ventilation. Few units routinely use dextran or dobutamine infusions, although one-to-one nursing and invasive cardiovascular monitoring are commonplace. Alternative provision of postoperative care is discussed. © 2008 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Free flap; Postal survey; Post operative care
One of the main treatment modalities for the treatment of mucosal head and neck squamous cell carcinomas is surgical excision of the tumour, with reconstruction where appropriate. Depending on the site, size and complexity of the defect, the reconstruction may involve free tissue transfer grafts of soft tissue, bone or a composite of both. The operation is complex and lengthy (often more than 8–10 hours). Other problems include the common co-morbidities in these patients, particularly heavy smoking, alcohol abuse and age related conditions, and these may delay hospital discharge.1 High dependency care is usually required postoperatively. The typical hospital stay is 7–10 days, but this may be delayed by several weeks, especially if there is flap failure.1,2 Although the mortality of this type of surgery is low, the ∗ Corresponding author. Department of Anaesthetics, Queen Alexandra Hospital, Portsmouth, PO6 3LY. Fax: +44 02392 286681. E-mail address: [email protected] (S. Elliott).
physical and psychological impact on the patient is significant. These operations also involve a large investment of resources, in both time and monetary terms. Despite these issues, there is only limited published clinical outcome data to recommend the best postoperative care of these patients. A recent review suggested that the majority of patients do not require the routine use of an intensive care unit (ICU) in the immediate postoperative period.3 It was suggested that the use of a ‘specialist care’, high-dependency unit (HDU) or ward is cost effective, without reducing quality of care. Practices such as postoperative sedation and ventilation or use of cardio active drugs are controversial and usually based on departmental and personal preferences. Increasing financial constraints and pressure on Critical Care resources, have called traditional practices into question. With this in mind, we wanted to establish the current standard of immediate postoperative care for patients having free flap reconstruction following ablative head and neck surgery in the UK, and
0266-4356/$ – see front matter © 2008 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2008.06.004
M. Marsh et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 182–185 Table 1 Number of Free Flap Head and Neck reconstruction cases performed by Units per year Number of cases performed per year
Number of units
1 to 9 10 to 19 20 to 39 40 to 59 >60
3 17 26 8 3
conducted a national postal survey of head and neck cancer units.
Method Using the British Association of Oral and Maxillofacial Surgeons database of oral and maxillofacial hospital units, 140 separate units were identified. A questionnaire was sent to the lead clinician of each unit. Information was requested concerning the location, size and type of unit. If they performed free flap reconstruction surgery they were asked, if presented with a hypothetical, uncomplicated free flap case, where the patient would be cared for in the immediate postoperative period and more importantly, what was the type of care and therapy they would receive. Replies remained anonymous. A stamped, self-addressed envelope was included with each questionnaire.
Results Out of 140 questionnaires sent out, 83 replies were received (59% response rate). Of these replies, 57 units performed Head and Neck free flap reconstruction surgery, and these results were used in the subsequent analysis. District General Hospitals constituted 57% of units with teaching hospital units forming the remaining 43%. There was a considerable variation in the number of cases performed per year (Table 1). When presented with a hypothetical, uncomplicated free flap case, the majority of units (87%) would send their patients to either an intensive care unit (ICU) (54%) or high dependency unit (HDU)(33%), (Table 2). The remaining Units would routinely use an extended theatre recovery (3.5%), head and neck unit (7%) or general ward (1.8%). There seemed to be no
183
Table 2 Location of care for the first postoperative night Place of postoperative care
Number of units
Intensive care unit High dependency unit General ward Head and neck unit Extended theatre recovery
31 19 1 4 2
Table 3 Details of those Units sending routine patients postoperatively to locations other than Intensive Care Unit (ITU) or High Dependency Unit (HDU) Type of Hospital
Number of cases per year
Location of postoperative care
District General Teaching Teaching Teaching Teaching District General Teaching
10–19 20–39 20–39 20–39 20–39 20–39 >60
Head and Neck Unit Extended Recovery Head and Neck Unit Extended Recovery General Ward Head and Neck Unit Head and Neck Unit
relationship between this decision and the size or type of unit (Table 3). The survey revealed considerable variation in the postoperative management of patients (Table 4). While most airways were managed with a tracheostomy there was a striking variation in the routine use of postoperative ventilation. For those units which did electively ventilate their patients postoperatively, this was usually only for 4–24 hours. Invasive cardiovascular monitoring was extremely common with 87% of units monitoring arterial blood pressure usually or almost always. However, 5% of units almost never did this. Corresponding figures for monitoring the central venous pressure were 78% usually or almost always and 7% almost never. Only 5% of units routinely used cardiovascular drugs, 63% almost never. Similarly only 9% of units routinely use intravascular dextran infusions, and 77% almost never use dextran.
Discussion We did not have access to a list of all hospitals in the UK which perform Head and Neck free flap reconstruction surgery. Therefore we sent questionnaires to all hospitals performing maxillo-facial surgery, expecting a lower response rate from
Table 4 Management of patients on the first postoperative night (%)
Elective tracheostomy Planned intubation Planned overnight ventilation 1 to 1 nursing care Invasive arterial pressure monitoring Central venous pressure monitoring Use of cardiovascular drugs Use of Dextran infusion
Almost always
Usually
Occasionally
Almost Never
22 (39) 4 (7) 16 (28) 34 (60) 35(61) 31 (54) 2 (3) 3 (5)
17 (30) 10 (17) 15 (26) 14 (25) 15 (26) 13 (23) 3 (5) 2 (3)
13 (23) 22 (39) 13 (23) 3 (5) 4(7) 8 (14) 15 (26) 7 (12)
5 (9) 16 (28) 12 (21) 4 (7) 3 (5) 4 (7) 36 (63) 44 (77)
184
M. Marsh et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 182–185
those not performing free flaps. This would explain our 59% response rate overall. Of the replies that we did receive, 69% did perform free flap reconstructions. We therefore believe that our survey is likely to be representative of the immediate postoperative care of these patients. This type of surgery is performed in many units around the country, both in District General and Teaching Hospitals, and there was a wide variability in the number of cases performed by each unit per year. Only three units perform greater than 60 cases and 20% of units performed less than 20 per year. We did not ascertain the number of surgeons or anaesthetists involved and thus cannot comment on how many cases an individual might perform per year. These figures are notable in the current climate of centralising complex surgical services to major specialist centres. Traditionally, the postoperative care of head and neck free flap patients involves an elective admission to an ICU. Due to increasing financial constraints and pressure on critical care resources this view is becoming increasingly challenged. In our survey, when presented with a hypothetical, uncomplicated free flap case, the great majority of units would send their patients to an ICU (54%) or HDU (33%). However, the published literature on the subject of postoperative care after these free flap cases is minimal. Our results are in agreement with another recent study that looked at post-operative management of free tissue transfer in the UK.4 Although their postal study predominantly focused on post-operative flap management, they also included as part of their questionnaire the immediate post-operative location of these. Broadly speaking, they found that only 15% of units sent their patients to a non ICU/HDU environment (in our study this was 13%). Godden et al undertook a retrospective comparative review of the data collected from two neighbouring head and neck cancer units.5 The only difference between the two units was that one sent the patients to a general ward with ‘special care’ for 48 hours and the other sent the patient to ICU (without ventilation). The study concluded that there was no difference in morbidity and that such practice is safe under certain conditions. Another study described a series of 268 various major head and neck cases that were largely managed on a general ward with ‘specialist nursing care.6 ’ The author concluded that this practice was safe and cost effective. An editorial in the same journal merely stated that these were the only two relevant papers in world literature, the numbers were too small, and that a prospective multicentre trial with adequate numbers is required to give any meaningful data.7 The editorial also pointed out that definitions of ICU, “special ward”, general ward and details of the actual care received there is probably different between hospitals and countries. A recent review from the UK advocated that the majority of head and neck free flap patients do not require the routine use of an intensive care unit (ICU) in the immediate postoperative period.3 It was suggested that the use of a ‘specialist care’, high-dependency unit (HDU) or ward is cost effective, without reducing quality of care.
Reasons for admission to a critical care unit would include management of the compromised airway, maximising flap survival rates and general care of the postoperative patient. The postoperative airway is potentially compromised by pre-existing problems, localised tissue and flap swelling and haematoma formation. However, there is no published evidence which shows that ICU admission leads to increased flap survival. Our survey shows that 69% of Units would electively perform a tracheostomy ‘usually’ or ‘almost always’. Whether new tracheostomy stomas can be safely managed anywhere but an ICU is contentious and the policy usually depends on local factors. Some units (24%) would appear to usually avoid the added morbidity of a tracheostomy and manage the early postoperative patient with an endotracheal tube, usually involving a degree of sedation and admission to an ICU. Most tracheostomy related complications occur on the ward rather than ICU.8 Traditionally the patient is kept sedated and relatively immobile to protect the airway and prevent shearing stresses on the anastomoses. This would usually involve a period of ventilation. For our hypothetical, straightforward patient, 44% of units would routinely ventilate post-operatively ‘almost never’ or ‘occasionally’. Of those that do this was often only for several hours and none would aim to ventilate for more than 24 hours. This spectrum of policy may reflect a growing appreciation of the hazards of sedation and ventilation, such as acquired infection as well as the use of shorter acting anaesthetic drugs allowing a more rapid recovery. To avoid internal vessel factors leading to flap failure, the patient is traditionally kept warm and vasodilated using external heaters, aggressive fluid optimisation regimes and where necessary vasoactive infusions such as dobutamine. Various drugs have been advocated to reduce anastomotic thrombosis, such as dextran to prevent platelet aggregation. Our survey showed that dextran and cardiovascular drugs such as dobutamine are not now commonly used for these patients. A large study found that dextran had no benefit in these patients.9 Although it is clear that a period of high care is required for these patients, quite where that is provided remains in question. Few patients seem to require the ventilation, vasoactive infusions and organ support provided in a true ICU setting. They do however seem to need individual nursing care, close cardiovascular monitoring, and the care of a tracheostomy in a sedated patient. Given these requirements it will be interesting to see how in the future, this may be provided more cheaply and perhaps provided more reliably by specialised Head and Neck or Overnight Intensive Recovery Units. In our survey such Units were routinely utilised by only 5 units. In summary, our survey shows variation in the care of these patients. This is due in part to local factors but is also due to a lack of published data showing the effect of different
M. Marsh et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 182–185
types of postoperative care on outcome. The lack of robust data is likely to continue with the presence of multiple small units. Amalgamation of data into a national database would seem logical to inform decision-making but also to allow meaningful analysis of unit performance.
References 1. Beausang ES, Ang EE, Lipa JE, et al. Microvascular free tissue transfer in elderly patients: the Toronto experience. Head and Neck 2003;25: 549–53. 2. Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A, Mehrara BJ. Free flap re-exploration: indications, treatment, and outcomes in 1193 free flaps. Plastic and Reconstructive Surgery 2007;119:2092–100. 3. Bradley PJ. Should all head and neck cancer patients be nursed in intensive therapy units following major surgery? Current Opinions in Otolaryngology and Head and Neck Surgery 2007;15:63–7.
185
4. Whitaker IS, Gulati V, Ross GL, Menon A, Ong TK. Variations in the postoperative management of free tissue transfers to the head and neck in the United Kingdom. British Journal of Oral and Maxillofacial Surgery 2007;45:16–8. 5. Godden DR, Patel M, Baldwin A, Woodwards RT. Need for intensive care after operations for head and neck cancer surgery. British Journal of Oral and Maxillofacial Surgery 1999;37:502–5. 6. To EW, Tsang WM, Lai EC, Chu MC. A retrospective study on the need of ICU admission after major head and neck surgery. ANZ Journal of Surgery 2002;72:11–4. 7. Editorial: The need of ICU admission after major head and neck surgery. ANZ Journal of Surgery 2002; 72:3–4. 8. Halfpenny W, McGurk M. Analysis of tracheostomy-related morbidity after operations for head and neck Cancer. British Journal of Oral and Maxillofacial Surgery 2000;38:509–12. 9. Disa JJ, Polvora VP, Pusic AL, Singh B, Cordeiro PG. Dextran-related complications in head and neck microsurgery: do the benefits outweigh the risks? A prospective randomized analysis. Plastic and Reconstructive Surgery 2003;112:1534–9.
British Journal of Oral and Maxillofacial Surgery 47 (2009) 182–185
Early postoperative care for free flap head & neck reconstructive surgery - a national survey of practice M. Marsh a , S. Elliott a,∗ , R. Anand b , P.A. Brennan b a b
Department of Anaesthetics, Queen Alexandra Hospital, Portsmouth, PO6 3LY, United Kingdom Department of Maxillofacial Surgery, Queen Alexandra Hospital, Portsmouth, PO6 3LY, United Kingdom
Accepted 8 June 2008 Available online 21 July 2008
Abstract There is considerable variation in the post-operative management of head and neck free flaps in the UK. We undertook a national postal survey of maxillofacial surgical units in the UK who perform free flap reconstruction following ablative head and neck surgery. Questions were asked about the routine postoperative care of a hypothetical, straightforward patient undergoing free flap reconstruction to determine whether there were any trends in managing these patients. There was considerable variation in the number of free flaps performed by each unit per year. The majority of patients (87%) are managed in either an intensive care or high dependency unit. The routine use of a tracheostomy is common (69%). There was also variation in the management of these cases, particularly with the requirement for ventilation. Few units routinely use dextran or dobutamine infusions, although one-to-one nursing and invasive cardiovascular monitoring are commonplace. Alternative provision of postoperative care is discussed. © 2008 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Free flap; Postal survey; Post operative care
One of the main treatment modalities for the treatment of mucosal head and neck squamous cell carcinomas is surgical excision of the tumour, with reconstruction where appropriate. Depending on the site, size and complexity of the defect, the reconstruction may involve free tissue transfer grafts of soft tissue, bone or a composite of both. The operation is complex and lengthy (often more than 8–10 hours). Other problems include the common co-morbidities in these patients, particularly heavy smoking, alcohol abuse and age related conditions, and these may delay hospital discharge.1 High dependency care is usually required postoperatively. The typical hospital stay is 7–10 days, but this may be delayed by several weeks, especially if there is flap failure.1,2 Although the mortality of this type of surgery is low, the ∗ Corresponding author. Department of Anaesthetics, Queen Alexandra Hospital, Portsmouth, PO6 3LY. Fax: +44 02392 286681. E-mail address: [email protected] (S. Elliott).
physical and psychological impact on the patient is significant. These operations also involve a large investment of resources, in both time and monetary terms. Despite these issues, there is only limited published clinical outcome data to recommend the best postoperative care of these patients. A recent review suggested that the majority of patients do not require the routine use of an intensive care unit (ICU) in the immediate postoperative period.3 It was suggested that the use of a ‘specialist care’, high-dependency unit (HDU) or ward is cost effective, without reducing quality of care. Practices such as postoperative sedation and ventilation or use of cardio active drugs are controversial and usually based on departmental and personal preferences. Increasing financial constraints and pressure on Critical Care resources, have called traditional practices into question. With this in mind, we wanted to establish the current standard of immediate postoperative care for patients having free flap reconstruction following ablative head and neck surgery in the UK, and
0266-4356/$ – see front matter © 2008 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2008.06.004
M. Marsh et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 182–185 Table 1 Number of Free Flap Head and Neck reconstruction cases performed by Units per year Number of cases performed per year
Number of units
1 to 9 10 to 19 20 to 39 40 to 59 >60
3 17 26 8 3
conducted a national postal survey of head and neck cancer units.
Method Using the British Association of Oral and Maxillofacial Surgeons database of oral and maxillofacial hospital units, 140 separate units were identified. A questionnaire was sent to the lead clinician of each unit. Information was requested concerning the location, size and type of unit. If they performed free flap reconstruction surgery they were asked, if presented with a hypothetical, uncomplicated free flap case, where the patient would be cared for in the immediate postoperative period and more importantly, what was the type of care and therapy they would receive. Replies remained anonymous. A stamped, self-addressed envelope was included with each questionnaire.
Results Out of 140 questionnaires sent out, 83 replies were received (59% response rate). Of these replies, 57 units performed Head and Neck free flap reconstruction surgery, and these results were used in the subsequent analysis. District General Hospitals constituted 57% of units with teaching hospital units forming the remaining 43%. There was a considerable variation in the number of cases performed per year (Table 1). When presented with a hypothetical, uncomplicated free flap case, the majority of units (87%) would send their patients to either an intensive care unit (ICU) (54%) or high dependency unit (HDU)(33%), (Table 2). The remaining Units would routinely use an extended theatre recovery (3.5%), head and neck unit (7%) or general ward (1.8%). There seemed to be no
183
Table 2 Location of care for the first postoperative night Place of postoperative care
Number of units
Intensive care unit High dependency unit General ward Head and neck unit Extended theatre recovery
31 19 1 4 2
Table 3 Details of those Units sending routine patients postoperatively to locations other than Intensive Care Unit (ITU) or High Dependency Unit (HDU) Type of Hospital
Number of cases per year
Location of postoperative care
District General Teaching Teaching Teaching Teaching District General Teaching
10–19 20–39 20–39 20–39 20–39 20–39 >60
Head and Neck Unit Extended Recovery Head and Neck Unit Extended Recovery General Ward Head and Neck Unit Head and Neck Unit
relationship between this decision and the size or type of unit (Table 3). The survey revealed considerable variation in the postoperative management of patients (Table 4). While most airways were managed with a tracheostomy there was a striking variation in the routine use of postoperative ventilation. For those units which did electively ventilate their patients postoperatively, this was usually only for 4–24 hours. Invasive cardiovascular monitoring was extremely common with 87% of units monitoring arterial blood pressure usually or almost always. However, 5% of units almost never did this. Corresponding figures for monitoring the central venous pressure were 78% usually or almost always and 7% almost never. Only 5% of units routinely used cardiovascular drugs, 63% almost never. Similarly only 9% of units routinely use intravascular dextran infusions, and 77% almost never use dextran.
Discussion We did not have access to a list of all hospitals in the UK which perform Head and Neck free flap reconstruction surgery. Therefore we sent questionnaires to all hospitals performing maxillo-facial surgery, expecting a lower response rate from
Table 4 Management of patients on the first postoperative night (%)
Elective tracheostomy Planned intubation Planned overnight ventilation 1 to 1 nursing care Invasive arterial pressure monitoring Central venous pressure monitoring Use of cardiovascular drugs Use of Dextran infusion
Almost always
Usually
Occasionally
Almost Never
22 (39) 4 (7) 16 (28) 34 (60) 35(61) 31 (54) 2 (3) 3 (5)
17 (30) 10 (17) 15 (26) 14 (25) 15 (26) 13 (23) 3 (5) 2 (3)
13 (23) 22 (39) 13 (23) 3 (5) 4(7) 8 (14) 15 (26) 7 (12)
5 (9) 16 (28) 12 (21) 4 (7) 3 (5) 4 (7) 36 (63) 44 (77)
184
M. Marsh et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 182–185
those not performing free flaps. This would explain our 59% response rate overall. Of the replies that we did receive, 69% did perform free flap reconstructions. We therefore believe that our survey is likely to be representative of the immediate postoperative care of these patients. This type of surgery is performed in many units around the country, both in District General and Teaching Hospitals, and there was a wide variability in the number of cases performed by each unit per year. Only three units perform greater than 60 cases and 20% of units performed less than 20 per year. We did not ascertain the number of surgeons or anaesthetists involved and thus cannot comment on how many cases an individual might perform per year. These figures are notable in the current climate of centralising complex surgical services to major specialist centres. Traditionally, the postoperative care of head and neck free flap patients involves an elective admission to an ICU. Due to increasing financial constraints and pressure on critical care resources this view is becoming increasingly challenged. In our survey, when presented with a hypothetical, uncomplicated free flap case, the great majority of units would send their patients to an ICU (54%) or HDU (33%). However, the published literature on the subject of postoperative care after these free flap cases is minimal. Our results are in agreement with another recent study that looked at post-operative management of free tissue transfer in the UK.4 Although their postal study predominantly focused on post-operative flap management, they also included as part of their questionnaire the immediate post-operative location of these. Broadly speaking, they found that only 15% of units sent their patients to a non ICU/HDU environment (in our study this was 13%). Godden et al undertook a retrospective comparative review of the data collected from two neighbouring head and neck cancer units.5 The only difference between the two units was that one sent the patients to a general ward with ‘special care’ for 48 hours and the other sent the patient to ICU (without ventilation). The study concluded that there was no difference in morbidity and that such practice is safe under certain conditions. Another study described a series of 268 various major head and neck cases that were largely managed on a general ward with ‘specialist nursing care.6 ’ The author concluded that this practice was safe and cost effective. An editorial in the same journal merely stated that these were the only two relevant papers in world literature, the numbers were too small, and that a prospective multicentre trial with adequate numbers is required to give any meaningful data.7 The editorial also pointed out that definitions of ICU, “special ward”, general ward and details of the actual care received there is probably different between hospitals and countries. A recent review from the UK advocated that the majority of head and neck free flap patients do not require the routine use of an intensive care unit (ICU) in the immediate postoperative period.3 It was suggested that the use of a ‘specialist care’, high-dependency unit (HDU) or ward is cost effective, without reducing quality of care.
Reasons for admission to a critical care unit would include management of the compromised airway, maximising flap survival rates and general care of the postoperative patient. The postoperative airway is potentially compromised by pre-existing problems, localised tissue and flap swelling and haematoma formation. However, there is no published evidence which shows that ICU admission leads to increased flap survival. Our survey shows that 69% of Units would electively perform a tracheostomy ‘usually’ or ‘almost always’. Whether new tracheostomy stomas can be safely managed anywhere but an ICU is contentious and the policy usually depends on local factors. Some units (24%) would appear to usually avoid the added morbidity of a tracheostomy and manage the early postoperative patient with an endotracheal tube, usually involving a degree of sedation and admission to an ICU. Most tracheostomy related complications occur on the ward rather than ICU.8 Traditionally the patient is kept sedated and relatively immobile to protect the airway and prevent shearing stresses on the anastomoses. This would usually involve a period of ventilation. For our hypothetical, straightforward patient, 44% of units would routinely ventilate post-operatively ‘almost never’ or ‘occasionally’. Of those that do this was often only for several hours and none would aim to ventilate for more than 24 hours. This spectrum of policy may reflect a growing appreciation of the hazards of sedation and ventilation, such as acquired infection as well as the use of shorter acting anaesthetic drugs allowing a more rapid recovery. To avoid internal vessel factors leading to flap failure, the patient is traditionally kept warm and vasodilated using external heaters, aggressive fluid optimisation regimes and where necessary vasoactive infusions such as dobutamine. Various drugs have been advocated to reduce anastomotic thrombosis, such as dextran to prevent platelet aggregation. Our survey showed that dextran and cardiovascular drugs such as dobutamine are not now commonly used for these patients. A large study found that dextran had no benefit in these patients.9 Although it is clear that a period of high care is required for these patients, quite where that is provided remains in question. Few patients seem to require the ventilation, vasoactive infusions and organ support provided in a true ICU setting. They do however seem to need individual nursing care, close cardiovascular monitoring, and the care of a tracheostomy in a sedated patient. Given these requirements it will be interesting to see how in the future, this may be provided more cheaply and perhaps provided more reliably by specialised Head and Neck or Overnight Intensive Recovery Units. In our survey such Units were routinely utilised by only 5 units. In summary, our survey shows variation in the care of these patients. This is due in part to local factors but is also due to a lack of published data showing the effect of different
M. Marsh et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 182–185
types of postoperative care on outcome. The lack of robust data is likely to continue with the presence of multiple small units. Amalgamation of data into a national database would seem logical to inform decision-making but also to allow meaningful analysis of unit performance.
References 1. Beausang ES, Ang EE, Lipa JE, et al. Microvascular free tissue transfer in elderly patients: the Toronto experience. Head and Neck 2003;25: 549–53. 2. Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A, Mehrara BJ. Free flap re-exploration: indications, treatment, and outcomes in 1193 free flaps. Plastic and Reconstructive Surgery 2007;119:2092–100. 3. Bradley PJ. Should all head and neck cancer patients be nursed in intensive therapy units following major surgery? Current Opinions in Otolaryngology and Head and Neck Surgery 2007;15:63–7.
185
4. Whitaker IS, Gulati V, Ross GL, Menon A, Ong TK. Variations in the postoperative management of free tissue transfers to the head and neck in the United Kingdom. British Journal of Oral and Maxillofacial Surgery 2007;45:16–8. 5. Godden DR, Patel M, Baldwin A, Woodwards RT. Need for intensive care after operations for head and neck cancer surgery. British Journal of Oral and Maxillofacial Surgery 1999;37:502–5. 6. To EW, Tsang WM, Lai EC, Chu MC. A retrospective study on the need of ICU admission after major head and neck surgery. ANZ Journal of Surgery 2002;72:11–4. 7. Editorial: The need of ICU admission after major head and neck surgery. ANZ Journal of Surgery 2002; 72:3–4. 8. Halfpenny W, McGurk M. Analysis of tracheostomy-related morbidity after operations for head and neck Cancer. British Journal of Oral and Maxillofacial Surgery 2000;38:509–12. 9. Disa JJ, Polvora VP, Pusic AL, Singh B, Cordeiro PG. Dextran-related complications in head and neck microsurgery: do the benefits outweigh the risks? A prospective randomized analysis. Plastic and Reconstructive Surgery 2003;112:1534–9.