key: cord-0758487-u7twj8p2 authors: Pontell, Matthew E.; Alving-Trinh, Alexandra L.; Chaker, Sara; Winocour, Julian S.; Thayer, Wesley P. title: Free Tissue Transfer during the COVID-19 Pandemic: A Proposed Evidence-Based Protocol for Early Discharge date: 2022-03-03 journal: World J Plast Surg DOI: 10.52547/wjps.11.1.23 sha: 431614504ec4a5a64159884bd64f43c644459f73 doc_id: 758487 cord_uid: u7twj8p2 BACKGROUND: As free tissue transfer outcomes improve, institutions are examining early discharge protocols. “Early” is generally defined as between one and five days postoperatively, which correlates with the timing of most major complications and most opportunities for flap salvage. Given the trend towards early discharge, the need for healthcare cost reductions and shortage of ICU beds during a viral pandemic, we aimed to propose an evidence-based protocol to select patients for discharge within 72 h of free tissue transfer. METHODS: A retrospective review of all patients who underwent free tissue transfer at Vanderbilt University Medical Center, Tennessee, USA since the onset of the COVID-19 (2020-2021) pandemic was performed. Patients were included for review if they were discharged within 72 h of surgery. Literature relating to expedited discharge after free tissue transfer was also reviewed. RESULTS: Six patients met inclusion criteria for retrospective review. None suffered intraoperative or postoperative inpatient complications and all were discharged within 72 h postoperatively. There were no flap failures within 30 d of reconstruction. CONCLUSION: This study reviews a patient cohort undergoing free tissue transfer during the COVID-19 pandemic. These cases were reviewed for factors that may have contributed to their postoperative success after discharge within 72 hours. These data points were combined with published evidence on risks for failure after free flap reconstruction to design a protocol to select patients for early discharge. The benefits of early discharge include reducing healthcare costs, risks of inpatient hospitalization, and ICU utilization, which is of paramount importance in the midst of a global pandemic.. Severe wounds compromised by critical structure exposure often require reconstruction by free tissue transfer. As microvascular reconstruction has become more commonplace and institutional experiences increase, outcomes have subsequently improved [1] [2] [3] [4] [5] . Free tissue transfer is now an established tool used to maximize outcomes after reconstruction of post-traumatic, post-infectious and post-extirpative defects [6] [7] [8] . A relative disadvantage of microvascular free tissue transfer is the length of surgery and degree of post-operative care. Average length of stay (LOS) for such patients ranges from 1 to 4 wk depending on the nature of the defect, patient comorbid status, flap selection and postoperative course [9] [10] [11] [12] [13] [14] [15] . LOS is highly variable in this patient population and is related to the need for close postoperative observation, physical rehabilitation, consolidation of wound care and the ability to arrange ancillary services needed to safely discharge 12 . Nevertheless, an extended LOS translates into a significant increase in hospital cost [15] [16] [17] . As free tissue transfer gains popularity and surgeons become more comfortable, outcomes continue to improve, with free flap failure rates quoted as low as 1%-2% in some series 14, [18] [19] [20] [21] [22] [23] . This has given rise to trends towards early discharge for patients with few medical comorbidities and are otherwise deemed "low-risk" by their surgeons 7, 14, 15 . Aside from decreasing healthcare costs, truncating postoperative LOS decreases patientcentric risks associated with prolonged hospitalization 14 . Discharge in as few as 1-3 d postoperatively has been shown to be safe in appropriately selected patients for free tissue reconstruction 14 . The year 2020 has brought with it many challenges, none as great as COVID-19. The viral pandemic has strained hospital systems across the globe and resulted in substantial intensive care unit (ICU) bed shortages in the United States 24 . This has resulted in a difficult situation for patients requiring microvascular reconstruction in the time of the pandemic. Given the need for ICU beds and decreased hospital systems utilization, expedited discharge protocols are needed now more than ever. We aimed to examine a single-institution's experience during the COVID-19 pandemic alongside published literature to propose a protocol for discharge within 72 h of free tissue transfer. After Institutional Review Board approval (IRB 210044), a retrospective chart review was conducted at Vanderbilt University Medical Center, Tennessee, USA. Patients who underwent free tissue transfer from 2020-2021, during the time of the COVID-19 pandemic, were identified. Those patients discharged within 72 h postoperatively were selected for analysis. Data from the preoperative, intraoperative, and postoperative periods were analyzed. Descriptive statistics were utilized with means and ranges plus or minus standard deviations when appropriate. Criteria consistent among patients was identified again compared to existing literature that has shown to be predictive of complications and prolonged LOS after free tissue transfer. A protocol was then proposed to identify patients who are appropriate for discharge within 72 h after free tissue transfer. Six patients met inclusion criteria for the retrospective review. There were four males and two females, with an average age of 44.7 years. All patients (6/6) were admitted electively for their procedure and no patient had a history of chronic steroid usage, radiation to the wound bed or a preoperative diagnosis of a bleeding diathesis. All patients were ASA class 3 or lower (Table 1) . Five patients underwent free fascia-. only flap reconstruction and one patient underwent free fasciocutaneous flap reconstruction. All flaps were based on perforators from the descending branch of the lateral femoral circumflex artery. There were no intraoperative complications and no patients required intraoperative transfusions. In every case, surgery time was less than 360 min and intraoperative crystalloid transfusion was 2,900 cc or less ( Table 2) (Table 3) . Although free flap failure rates continue to decline, postoperative complications are not infrequent 1, 6, 7, 9, [25] [26] [27] [28] [29] [30] . Complication rates from 15%-30% in certain cohorts are reported 1 . However, most data corroborates that the majority of complications occur within 48-72 h postoperatively [31] [32] [33] . This correlates with the fact that the best opportunity for flap salvage is within the same timeframe 12,31,34-39 . Postoperative monitoring protocols vary greatly between institution; however, most surgeons monitor their patients between five to seven days prior to discharge 32, 33 . This highlights the discrepancy between the timing of complications and the length of postoperative monitoring, as the effectiveness of flap monitoring beyond 72 h has been questioned 39 . This discordance has led to the exploration of early discharge after free tissue transfer. While several institutions have subscribed to the belief that some patients are over-monitored, there has not yet been a defined protocol to identify patients who may Multiple studies have examined potential risk factors for suboptimal outcomes after free tissue transfer. Identified preoperative risk factors for postoperative complications and/or prolonged LOS include a preoperative diagnosis of a bleeding disorder, preoperative albumin level of less than 3.5g/dL, increasing ASA class and a preoperative diagnosis of anemia 1, 40 . Notably a preoperative diagnosis of diabetes mellitus has also been associated with complications. While a preoperative diagnosis should not excluded patients from the benefit of free tissue reconstruction, these patients may not be appropriate for expedited discharge 1,41-43 . In the head and neck literature, pre-operative radiation therapy was also associated with prolonged LOS 15 . While a prerogative diagnosis of coronary artery disease (CAD) is a significant predictor or morbidity in many surgeries, there is a lack of consensus on its risk in free flap reconstruction 14 . Additional risk factors include the preoperative use of steroids, which have not only been associated with wound complications, but also free flap failure and thrombosis 1,44 . Interestingly, age itself does not increase the risk of complications after free tissue transfer 45, 46 . Intraoperative risk factors include volume resuscitation greater than seven liters 7 and increasing operative time 1, 7, 47 . Several studies have shown increased complications and LOS with operative times exceeding 510-700 min 1, 7, 47 . Regardless of the exact duration, increasing operative time has been correlated with poorer outcomes in free flap surgery 1, [47] [48] [49] . In order to mitigate risks associated with prolonged operative time, institutions have adopted a two-team approach with one team working on recipient bed preparation while the other works on flap elevation 7, 14, [50] [51] [52] [53] . This is the approach used at our institution. After retrospectively reviewing our institutional experience with early discharge after free flap reconstruction during the COVID-19 pandemic, we identified factors that were consistent amongst these patients that also correlated with published literature. Using these preoperative and intraoperative values we proposed a protocol to select patients who may be candidates for discharge within 72 h of free tissue transfer ( Table 4 ). The protocol consists of two sections, the preoperative section identifies patients who are non-diabetic, have no history of radiation to the wound bed, do not use steroids chronically, do not have a preoperative bleeding disorder, are ASA 3 or less, do not have a preoperative diagnosis of anemia or hypoalbuminemia. The intraoperative section identifies patients who do not require intraoperative PRBC transfusion, receive less than seven liters of crystalloid infusion, have a total operative time of less than 540 min and undergo reconstruction by either fasciocutaneous or fasciaonly flaps. These criterion were based on the aforementioned study results 1, 7, 14, 15, [40] [41] [42] [43] [44] [45] [46] [47] [48] [49] [50] [51] [52] [53] , and flap selection criteria was included to minimize donor site morbidity associated with muscle-based flaps. This study has several limitations, most notably the cohort size. In addition, patients were retrospectively analyzed in order to isolate variables www.wjps.ir that are consistent with acceptable outcomes after early discharge. The protocol is a proposal and requires prospective validation alongside a properly controlled group. However, this algorithm serves as a starting point on which to build an evidence based system to select patients who may succeed with early discharge protocols. This study examined a series of patients undergoing free tissue based reconstruction during the COVID-19 pandemic. These cases were reviewed for factors that may have contributed to their postoperative success after discharge within 72 hours. These data points were combined with published evidence on risks for failure after free flap reconstruction to design a protocol to select patients for early discharge after free flap reconstruction. The benefits of early discharge include reduced associated healthcare costs and risks of inpatient hospitalization, as well as reducing ICU utilization which is of paramount importance in the midst of a global pandemic. 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