Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
Background: There is no clear consensus on where head and neck microvascular free-flap reconstruction patients should be managed postoperatively. Intensive care unit (ICU) admission remains routine at many institutions. However, recent literature has shown that patients admitted directly to the floor experience comparable outcomes to those managed in the ICU. There is limited literature highlighting the criteria for admitting head and neck free flap patients to the ICU at institutions where these patients are routinely managed on the floor.
Objective: Describe our tertiary care center’s initial experience admitting head and neck free flap patients to the floor and compare their outcomes to those admitted to the ICU postoperatively, before routine floor admission was established. Highlight the criteria utilized at our institution when determining initial patient disposition postoperatively.
Methods: A retrospective chart review of patients that underwent free tissue transfer reconstruction of the head and neck from 2017 to 2021 was performed. During the COVID-19 pandemic, our institution changed our practice from routine to selective ICU admission for free flap patients. Patients were divided into either the ICU or floor cohort based on initial postoperative disposition. Outcomes of interest included 30-day complications, flap success, unintended ICU admissions, diet advancement, and postoperative length of stay (LOS).
Results: 171 patients were included in our study, 105 of which were admitted to the ICU postoperatively, while 66 were admitted directly to the floor. Both ICU and floor patients experienced few complications within 30 days postoperatively. Of the patients initially admitted to the ICU, 3.8% experienced an unexpected return to the ICU. Only 3.0% of patients admitted directly to the floor required an unexpected ICU admission (p=0.787). 11.4% of ICU patients and 6.0% of floor patients required a return to the OR within 30 days (p=0.242). Regarding flap loss, 1.9% of ICU patients experienced a total flap loss compared to 3.0% of floor patients (p=0.638). Partial flap loss was observed in only 1.0% of ICU patients and was not observed in the floor patient cohort. Between ICU and floor patients, there were no statistically significant differences seen in postoperative rates of pneumonia, surgical dehiscence, or fistula formation. Wound healing was uncomplicated in 85.7% of ICU patients and 86.4% of floor patients (p=0.904). 48.6% of ICU patients resumed oral intake prior to discharge, compared to 62.1% of floor patients (p=0.084). 23.8% of ICU patients were discharged with nasogastric feeding, versus only 12.1% of floor patients (p=0.059). 42.9% of ICU patients were discharged with a gastrostomy tube versus 39.4% of floor patients (p=0.653). Average LOS for patients admitted to the ICU and floor directly were 8.5 days and 7.8 days, respectively (p=0.381).
Conclusions: Our results suggest that postoperative floor admission is safe for head and neck free flap reconstruction patients. Patients admitted directly to the floor had similar rates of complications and flap success compared to those admitted to the ICU. Rather than routine admission, institutions should establish ICU admission criteria for head and neck free flap patients to reduce healthcare cost and preserve ICU space.