Postoperative Care
The head and neck surgery team has been restructured to decrease the
risk of exposure to the entire team from a single patient or a single
team member with COVID-19. After anecdotes of department wide
quarantines due to possible COVID-19 exposure, we subdivided our head
and neck service into two independent teams. This was initiated at a
time when our institutional policy for suspected or confirmed COVID-19
exposure was self-quarantine.
The goal was that if one team had to quarantine the other would be able
to continue providing patient care. Each team has at least one ablative
and one reconstructive attending, one head and neck fellow, one senior
resident, and one intern. We have minimized interactions between teams
including separate rounding times and elimination of shared workspaces.
As mentioned previously, conferences are now virtual which also
eliminates physical interaction between teams. The frequency of team
rounding has moved from twice daily to once a day.
One of the biggest changes made in response to COVID-19 from a free flap
perspective is the postoperative flap monitoring protocol for intraoral
flaps by decreasing the frequency of flap checks. The goals were to
limit the use of PPE needed for flap checks and to limit surgical team
and nursing staff exposure risk. Our previous flap monitoring protocol
had been nursing flap checks every 1 hour for 24 hours (postoperative
day (POD) 1), every 2 hours for 48 hours (POD 2-3), every 4 hours for 72
hours (POD 4-6), then every 8 hours until discharge. Resident flap
checks were performed 6 hours immediately postoperatively, then every 12
hours for the first 72 hours, then once daily. Flap checks previously
included both implantable or external handheld Doppler sonography checks
as applicable and clinical examination of the skin paddle.
In our new flap monitoring protocol, nursing checks are performed at the
prior timing interval but only include checking the arterial and venous
implantable Doppler signals and an external skin paddle if applicable.
Importantly, the intraoral skin paddle is only checked every 6 hours or
if there is a change in Doppler signal, and requires use of proper PPE
for the exam. Resident intraoral skin paddle assessment is now performed
once at 6 hours postoperatively and then once daily on morning rounds.
These changes decrease the frequency of skin paddle examinations and
force a greater reliance on implantable Doppler sonography. Given this
increased reliance, we are now implanting both and arterial and venous
probe on all cases as mentioned above. Prior to this change, our
division protocol called for continuous implantable venous monitoring
for all flaps and clinical assessment of arterial perfusion in flaps
with a skin paddle amenable to exam.
Ultimately, our new protocol reduces the dependence on the postoperative
physical exam. Given that use of implantable doppler technology as an
indicator of flap perfusion is imperfect, it is reasonable to assume
that such a change in exam frequency could potentially lead to a
slightly higher flap failure rate during this time. As a division, this
is a risk we have accepted with the hope of reducing potential viral
exposures to our team. The effect of resident postoperative flap
monitoring frequency on flap survival rates, however, is unclear and
controversial. One recent multi-institutional study showed no difference
in flap survival rates with reduced resident monitoring
frequency12.