Donor site local anaesthetic infusion catheter as an opioid sparing agent in free flap reconstruction of the head and neck: a valuable adjunct to an enhanced recovery protocol

Surgery with free flap reconstruction is a standard treatment for head and neck cancer (HNC). Because of the complexity of HNC surgery, recovery can be challenging, and complications are common. One of the foundations of enhanced recovery after surgery (ERAS) is early postoperative mobilization. The ERAS guidelines for HNC surgery with free flap reconstruction recommend mobilization within 24 h. This is based mainly on evidence from other surgical disciplines, and the extent to which mobilization within 24 h improves recovery after HNC surgery has not been explored. This retrospective analysis included 445 patients from the Calgary Head and Neck Enhanced Recovery Program. Mobilization after 24 h was associated with more complications of any type (OR = 1.73, 95% CI [confidence interval] = 1.16–2.57) and more major complications (OR = 1.76; 95% CI = 1.00–3.16). When accounting for patient and clinical factors, mobilization after 48 h was a significant predictor of major complications (OR = 2.61; 95% CI = 1.10–6.21) and prolonged length of stay (>10 days; OR = 2.85, 95% CI = 1.41–5.76). This comprehensive analysis of the impact of early mobilization on postoperative complications and length of stay in a large HNC cohort provides novel evidence supporting adherence to the ERAS early mobilization recommendations. Early mobilization should be a priority for patients undergoing HNC surgery with free flap reconstruction.

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Comparing outcomes between traditional and enhanced recovery cohorts in major head and neck malignancy with free flap reconstruction

British Journal of Oral and Maxillofacial Surgery ◽

10.1016/j.bjoms.2020.10.076 ◽

2020 ◽

Vol 58 (10) ◽

pp. e158-e159

Author(s):

Yallan Nimalathas ◽

Sanjay Sharma

Keyword(s):

Head And Neck ◽

Free Flap ◽

Enhanced Recovery ◽

Flap Reconstruction ◽

Free Flap Reconstruction ◽

Head And Neck Malignancy ◽

Neck Malignancy

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Enhanced Recovery After Surgery–Based Perioperative Protocol for Head and Neck Free Flap Reconstruction

OTO Open ◽

10.1177/2473974x20931037 ◽

2020 ◽

Vol 4 (2) ◽

pp. 2473974X2093103 ◽

Cited By ~ 1

Author(s):

Caitlin Bertelsen ◽

Kevin Hur ◽

Margaret Nurimba ◽

Janet Choi ◽

Joseph R. Acevedo ◽

...

Keyword(s):

Blood Transfusion ◽

Length Of Stay ◽

Head And Neck ◽

Free Flap ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Control Group ◽

Flap Reconstruction ◽

Free Flap Reconstruction ◽

Flap Monitoring

Objectives Evaluate an enhanced recovery after surgery (ERAS)–based free flap management protocol implemented at our center. Study Design Prospective cohort study of patients after implementation of an ERAS-based perioperative care protocol for patients undergoing free flap reconstruction of the head and neck as compared with a historical control group. Setting Tertiary care academic medical center. Participants and Methods All patients undergoing free flap reconstruction were prospectively enrolled in the ERAS protocol group. A retrospective control group was identified by randomly selecting an equivalent number of patients from a records search of those undergoing free flap surgery between 2009 and 2015. Blood transfusion, complications, 30-day readmission rates, intensive care unit (ICU) and hospital length of stay, and costs of hospitalization were compared. Results Sixty-one patients were included in each group. Patients in the ERAS group underwent less frequent flap monitoring by physicians and had lower rates of intraoperative (70.5% vs 86.8%, P = .04) and postoperative (49.2% vs 27.2%, P = .026) blood transfusion, were more likely to be off vasopressors (98.3% vs 50.8%, P < .01) and ventilator support (63.9% vs 9.8%, P < .01) at the conclusion of surgery, and had shorter ICU stays (2.11 vs 3.39 days, P = .017). Length of stay, readmissions, and complication rates did not significantly differ between groups. Conclusion ERAS-based perioperative practices for head and neck free flap reconstruction can reduce time on the ventilator and in the ICU and the need for vasopressors, blood transfusions, and labor-intensive flap monitoring, without adverse effects on outcomes.

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From Pathways to Practice: Impact of Implementing Mobilization Recommendations in Head and Neck Cancer Surgery with Free Flap Reconstruction

Cancers ◽

10.3390/cancers13122890 ◽

2021 ◽

Vol 13 (12) ◽

pp. 2890

Author(s):

Rosie Twomey ◽

T. Wayne Matthews ◽

Steven C. Nakoneshny ◽

Christiaan Schrag ◽

Shamir P. Chandarana ◽

...

Keyword(s):

Head And Neck Cancer ◽

Head And Neck ◽

Neck Cancer ◽

Free Flap ◽

Clinical Decision Making ◽

Enhanced Recovery ◽

Hospital Length Of Stay ◽

Flap Reconstruction ◽

Free Flap Reconstruction ◽

Recommended Care

One of the foundational elements of enhanced recovery after surgery (ERAS) guidelines is early postoperative mobilization. For patients undergoing head and neck cancer (HNC) surgery with free flap reconstruction, the ERAS guideline recommends patients be mobilized within 24 h postoperatively. The objective of this study was to evaluate compliance with the ERAS recommendation for early postoperative mobilization in 445 consecutive patients who underwent HNC surgery in the Calgary Head and Neck Enhanced Recovery Program. This retrospective analysis found that recommendation compliance increased by 10% despite a more aggressive target for mobilization (from 48 to 24 h). This resulted in a decrease in postoperative mobilization time and a stark increase in the proportion of patients mobilized within 24 h (from 10% to 64%). There was a significant relationship between compliance with recommended care and time to postoperative mobilization (Spearman’s rho = −0.80; p < 0.001). Hospital length of stay was reduced by a median of 2 days, from 12 (1QR = 9–16) to 10 (1QR = 8–14) days (z = 3.82; p < 0.001) in patients who received guideline-concordant care. Engaging the clinical team and changing the order set to support clinical decision-making resulted in increased adherence to guideline-recommended care for patients undergoing major HNC surgery with free flap reconstruction.

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