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Surgical Outcomes Of Postoperative Intensive Care Unit Versus General Floor Management Following Lower Extremity Free Flap Reconstruction In The Comorbid Chronic Wound Population
Romina Deldar, MD1, John D. Bovill, BS2, Brian N. Truong, BS2, Nisha Gupta, MS2, Areeg A. Abu El Hawa, BS2, Kenneth L. Fan, MD1, Karen K. Evans, MD1.
1MedStar Georgetown University Hospital, Washington, DC, USA, 2Georgetown University School of Medicine, Washington, DC, USA.

PURPOSE: Free tissue transfer (FTT) lower limb salvage requires costly multidisciplinary care. Traditionally, patients who undergo FTT reconstruction for lower extremity (LE) wounds were admitted to the intensive care unit (ICU) in the immediate postoperative period for close monitoring. During the COVID-19 pandemic, our practice shifted towards admitting FTT patients to the general floor postoperatively instead of the ICU. This is the first study to compare surgical outcomes in patients admitted to the floor versus ICU immediately following free flap reconstruction for chronic LE wounds.
METHODS: A retrospective review was performed of patients undergoing FTT to LE from 2011 to 2021 by the senior author (K.K.E.). In March 2020, our institution began admitting our free flap patients to the general floor post-operatively. In patients admitted to the floor postoperatively, flap monitoring consisted of an implantable Cook-Swartz Doppler probe for muscle flaps and ViOptix tissue oximetry for fasciocutaneous flaps; clinical exam and hand-held dopplers were not the primary flap monitoring techniques. Patients were divided into two groups depending on whether they went to the ICU or specialty floor in the immediate postoperative period. Primary outcomes were postoperative complications, hospital length of stay (LOS), flap takeback and salvage, and flap success. Statistical significance was set at values of p < 0.05.
RESULTS: A total of 255 patients underwent FTT to LE during the 10-year period. Forty-two patients (16.5%) were admitted to the floor postoperatively and 213 patients (83.5%) went to the ICU. Average age and body mass index were 55.8 years and 29.4 kg/m2, respectively. Comorbidities among the two groups were similar, except floor patients had a higher prevalence of diabetes (69.0% vs. 49.3%, p=0.019). Overall microsurgical success rate was 97.3%, which was similar for floor and ICU patients (100% vs. 96.7%, p=0.604). Flap takeback occurred in 3 floor patients (1.2%) and 13 ICU patients (5.1%) (p=0.733). Flap salvage was higher in floor patients, although not statistically significant (7.1% vs. 3.3%, p=0.250). Average hospital LOS did not significantly differ among patients admitted to the floor versus ICU (16.1 vs. 17.7 days, p=0.628).
CONCLUSION: Our findings suggest that postoperative floor admission does not decrease flap success rates and should be considered in patients who undergo FTT to LE reconstruction and are otherwise stable. Efforts should be focused on training floor nurses to use the Cook Doppler and ViOptix devices to monitor flaps. While we expect hospital costs to decrease with floor admission, future studies should focus on the cost impact of postoperative floor management in this patient population.

Patient demographics, comorbidities, and surgical outcomes
Total (n=255)Floor admission (n=42)ICU admission (n=213)p-value
Age (yr)55.8 + 14.159.3 + 11.255.1 + 14.50.063
BMI (kg/m2)29.4 + 6.328.9 + 7.129.4 + 6.20.294
Diabetes134 (52.6%)29 (69.0%)105 (49.3%)0.019
Peripheral vascular disease84 (32.9%)26 (61.9%)58 (27.2%)<0.001
End-stage renal disease11 (4.3%)3 (7.1%)8 (3.8%)0.397
Flap takeback16 (6.3%)3 (7.1%)13 (6.1%)0.733
Flap salvage10 (62.5%)3 (7.1%)7 (3.3%)0.250
Flap success248 (97.3%)42 (100%)206 (96.7%)0.604
Hospital length of stay (days)17.4 + 10.116.1 + 8.117.7 + 10.40.628


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