Immediate postoperative care on high dependency unit or ward following microvascular free tissue transfer: lessons learnt from a change in practice imposed during the COVID-19 pandemic

Abstract

The COVID-19 pandemic resulted in sudden changes to the established practice of using high dependency (HDU) for the first night of postoperative care following microvascular free tissue transfer. Patients were managed instead on the head and neck ward. This retrospective case-note review aimed to report outcomes in consecutive patients treated before and during the pandemic and to reflect on the implications of ward-based care rather than HDU. 235 patients had free tissue transfer between 3 rd January 2019 and 25 th February 2021, 125 before the pandemic (lockdown 23 rd March 2020), and 110 during the pandemic (52 ward managed and 58 HDU managed). There were subtle case-mix differences during the pandemic, with 92% of ward treated patients having oral cancers compared with 64% of HDU patients and 73% of ward patients having a tracheostomy compared with 40% of HDU patients. Ward patients were less likely to receive electrolyte replacement (45% HDU Vs 0% Ward) and inotropes (12% HDU Vs 2% Ward). There were fewer returns to theatre for evacuation of haematoma or re-anastomosis during the pandemic than before. Other than fewer haematoma complications occurring during the pandemic the nature of complications was similar. In conclusion, the dramatic changes imposed by the pandemic have shown the ward to be a safe place for patients to be cared for immediately post-operatively and this alleviates bed pressures experienced in HDU. Careful case selection and clear criteria are required to identify patients needing HDU.

Airway decision making in major head and neck surgery: Irish multicenter, multidisciplinary recommendations

“…This has demonstrated that patients with a newly formed elective tracheostomy can safely be discharged to a specialist ward, with suitably qualified and trained staff, immediately following major head and neck oncologic surgery. [43][44][45] Clinicians should individualize the perioperative airway protection strategy for each patient and this should be discussed and agreed upon between the operating surgeon, anesthetist, and critical care staff preoperatively (Table 3). The superiority of elective tracheostomy over delayed extubation in providing a secure airway in the postoperative period is clear and it is absolutely indicated in complex surgery and patients with a higher risk airway (Tables 3 and 4).…”