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Rapid Recovery Protocol In Complex Head & Neck Reconstruction
Samir Rao, M.D.1, Mark W. Clemens, M.D.2, Peirong Yu, M.D.2.
1Georgetown University Hospital, Washington, DC, USA, 2MD Anderson Cancer Center, Houston, TX, USA.
PURPOSE: National surveys suggest standard practice for the majority of patients undergoing complex head and neck oncologic reconstructions with free tissue transfer is admission to an intensive care unit with maintenance on mechanical ventilation in the early postoperative period. Justification for this practice includes long operative times, patients with medical co-morbidities, lack of adequate non-ICU nursing, and deep sedation to protect the anastamosis from mechanical strain. However, recent literature supports immediate extubation in the operating room, and admission to non-ICU settings when possible. This study reviews a Rapid Recovery protocol (RRP) developed at the MD Anderson Cancer Center for select patients undergoing major head and neck reconstructions.
METHODS: All patients who underwent head and neck microvascular reconstructions performed by the senior author (P.Y.) between August 2001 and April 2011 were identified from a prospectively maintained patient database. Patients records were then reviewed for demographics, medical co-morbidities, adjunct therapies, reconstruction, operative time, complications, and length of stay. All categorical variables were compared with a Fisher’s exact test or chi-squared ( χ2) test, and a Student’s T-test was used for ordinal data . P values ≤ 0.05 were considered significant.
RESULTS: 565 consecutive patients underwent head and neck microvascular reconstructions during the study period. Of these patients, 529 were admitted to the ICU postoperatively while 36 underwent a rapid recovery protocol. Both groups had similar ages, BMI, and comorbidities. Complication rates for the ICU group for all complications (42.5%) and minor events (37.6%) were similar to the RRP group for all (38.9%) and minor (30.5%) events (p=0.730 and p=0.478, respectively) and were independent of donor site. Length of stay was significantly less (7.0 days) for the RRP group compared to the ICU group (10.2 days). (p=0.034), and for the 50-65 age stratification subgroup (6.3 versus 9.3, p=0.039). No RRP patients required transfer to ICU during their hospital stay. Although not achieving statistical significance, there were a total of 32 (5.7%) patients with major medical complications all occurring in the ICU group (p=0.129).
CONCLUSIONS: We conclude that the recovery of select patients with early extubation and mobilization is superior to ICU admission. The hazards of prolonged ventilation for major medical complications are confirmed. Candidates most benefiting from an RRP protocol are the elderly and those with significant comorbidities. A rapid recovery protocol is dependent upon accurate preoperative assessment, adequate postoperative airway, and maintenance of specialized free flap floor units with adequately trained nursing staff.
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