The Sars-CoV-2 (COVID-19) pandemic has resulted in significant and unprecedented shifts in the delivery of health care services in the United States. Although wound care remains an essential service ...during the COVID-19 pandemic, the financial consequences and infectious disease ramifications of the pandemic have resulted in closure or limitation of hours in many outpatient wound and hyperbaric oxygen therapy (HBOT) centers. As HBOT patients often require daily treatment sessions for a period of months, it is necessary for facilities providing HBOT services to adjust to the COVID-19 pandemic while still maintaining availability of this important service. Modification of HBOT session timing and chamber decontamination procedures, utilisation of telehealth services for initial patient evaluations, and acceptance of novel patient populations and diagnoses are mechanisms by which HBOT centers can adapt to the evolving model of health care delivery throughout a pandemic. While COVID-19 is not a currently accepted indication for HBOT, patients may be referred for HBOT consultation due to the post-infectious sequelae of the virus, and thus HBOT facilities must be aware of the potential uses of this treatment for post-viral complications. By redefining paradigms for health care delivery during the COVID-19 pandemic, HBOT and wound centers can continue to provide high-quality and uninterrupted care to vulnerable patient populations.
Background
Free tissue transfer (FTT) lower limb salvage requires costly multidisciplinary care. Traditionally, patients who undergo FTT reconstruction for lower extremity (LE) wounds were admitted ...to the intensive care unit (ICU) in the immediate postoperative period for close monitoring. During the COVID‐19 pandemic, our practice shifted toward admitting FTT patients to the floor postoperatively instead of the ICU. The purpose of this study is to compare surgical outcomes in patients admitted to the floor versus ICU immediately following LE free flap reconstruction.
Methods
We retrospectively reviewed patients undergoing LE FTT reconstruction from 2011 to 2021. Flap monitoring consisted of an implantable Cook‐Swartz Doppler probe for muscle flaps and ViOptix tissue oximetry for fasciocutaneous flaps; clinical exam and hand‐held dopplers were not the primary flap monitoring techniques. Patients were divided into two groups depending on whether they went to the ICU or floor postoperatively. To ensure proper comparability between cohorts, we corrected for age, BMI and Charlson Comorbidity Index (CCI) using 1:2 propensity score matching (floor: ICU). Primary outcomes included early postoperative complications, flap takeback and salvage, flap success, and postoperative length of stay (LOS).
Results
A total of 252 patients were identified. Forty‐five patients (17.9%) were admitted to the floor postoperatively and 207 patients (82.1%) to the ICU. Overall, microsurgical success rate was 97.2%, which was similar for floor and ICU patients. Flap takeback and salvage were similar between cohorts. Average postoperative LOS was significantly shorter in floor patients (15.7 vs. 19.1 days, p = 0.043).
Conclusion
Our findings suggest that postoperative floor admission does not decrease flap success rates and should be considered in patients who undergo FTT to LE reconstruction and are otherwise stable. In the ongoing era of health care cost containment, microsurgery centers should consider appropriate floor training to allow medically stable free flap patients to avoid an ICU stay.
Hyperbaric oxygen therapy (HBOT) is a useful adjunctive treatment for selected complicated wounds, including severe diabetic lower extremity ulcerations and compromised skin grafts or flaps. The ...Sars-CoV-2 (COVID-19) pandemic has disrupted healthcare delivery, with its effects extending to delivery of HBOT. During the pandemic, paediatric patients in our geographic region who were referred for HBOT faced challenges as centres temporarily closed or were unprepared to treat younger patients. Our monoplace HBOT centre modified existing practices to allow for treatment of these patients. This study aims to outline the steps necessary to adapting a pre-existing HBOT centre for the safe treatment of paediatric patients.
A retrospective review was performed to identify patients 18 years of age or younger referred for HBOT during 2020. Patient characteristics, referral indications and HBOT complications were collected. Changes implemented to the HBOT centre to accommodate the treatment of paediatric patients were documented.
A total of seven paediatric patients were evaluated for HBOT and six were treated. The mean patient age was four years (range: 1-11 years). Referral diagnoses included sudden sensorineural hearing loss, skin flap or graft compromise, and radiation-induced soft tissue necrosis. All patients tolerated HBOT treatment in monoplace chambers without significant complications noted. Enhancements made to our clinical practice to facilitate the safe and effective treatment of paediatric patients included ensuring the availability of acceptable garments for paediatric patients, maintaining uninterrupted patient grounding (in relation to fire safety), and enhancing social support for anxiety reduction.
The results of our review show that paediatric patients can be safely treated within the monoplace hyperbaric environment.
Limb salvage for chronic lower extremity wounds requires long-term care best delivered by specialized multidisciplinary centers. This optimizes function, reduces amputation rates, and improves ...mortality. These centers may be limited to urban/academic settings, making access and appropriate follow-up challenging. Therefore, the authors hypothesize that both system- and patient-related factors put this population at exceedingly high risk for loss to follow-up.
Records were reviewed retrospectively for 200 new patients seen at the Georgetown Center for Wound Healing in 2013. The primary outcome was loss to follow-up, defined as three consecutive missed appointments despite explicit documentation indicating the need for return visits. Demographic, clinical, and geographic data were compared. Multivariate logistic regression analysis for loss to follow-up status controlled for variables found significant in the bivariate analysis. Spatial dependency was evaluated using variograms.
Over a 6.5-year-period, 49.5 percent of patients followed were lost to follow-up. Male sex and increased driving distance to the limb salvage center were risk factors for loss to follow-up. Wound-specific characteristics including ankle and knee/thigh location were also associated with higher rates of loss to follow-up. There was no spatial dependency or discrete clustering of at-risk patients.
This study is the first of its kind to investigate the demographic and clinical characteristics that predispose chronic lower extremity wound patients to loss to follow-up. These findings inform stakeholders of the high rates of loss to follow-up and support decentralized specialty care, in the form of telemedicine, satellite facilities, and/or dedicated case managers. Future work will focus on targeting vulnerable populations through focused interventions to reduce patient and system burden.
Risk, III.
Despite the lack of clear indications for the use of intra-arterial lines (IALs) for intraoperative hemodynamic monitoring, they are often used in a variety of settings. In this retrospective review ...of patients undergoing free tissue transfer (FTT) for lower extremity (LE) reconstruction, we sought to (1) identify patient factors associated with IAL placement, (2) compare hemodynamic measurements obtained via IAL versus noninvasive blood pressure (NIBP) monitoring, and (3) investigate whether method of hemodynamic monitoring affected intraoperative administration of blood pressure-altering medications.
Patients undergoing LE FTT from January 2017 through June 2020 were retrospectively reviewed. Patients were pair matched based on flap donor site, sex, and body mass index to identify patient factors associated with IAL placement. Methods previously described by Bland and Altman (Lancet. 1986;327:307-310) were used to investigate agreement between IAL and NIBP measurements.
Sixty-eight patients were included with 34 patients in the IAL group and 34 in the NIBP group. Older patients (P = 0.03) and those with a higher Charlson Comorbidity Index (P = 0.05) were significantly more likely to have an IAL placed. Agreement analysis demonstrated that mean arterial pressures calculated from IAL readings were as much as 31 points lower or 28 points higher than those from NIBP. Bias calculations with this extent of difference suggest poor correlation between IAL readings and NIBP (R2 = 0.3027). There was no significant difference between groups in rate of administration of blood-pressure altering medications.
Surgeons should consider the risks and benefits of IAL placement on a case-by-case basis, particularly for patients who are young and healthy. Our findings highlight the need for clearer guidance regarding the use of IAL in patients undergoing LE FTT.
To identify the impact that HMG-CoA reductase inhibitors (statins) use has on wound healing outcomes in patients with comorbidities.
A retrospective chart review evaluating all new patients ...presenting to our tertiary wound care centre in 2013 with lower extremity wounds. Patients were divided into two groups depending on whether they took statins or not. Data on wound healing outcomes and wound/patient characteristics were collected. Primary outcomes included healing rate and progression to complete wound healing. Patients were excluded if they had incomplete data or were lost to follow-up before healing status could be confirmed.
A total of 194 patients met the inclusion criteria and were allocated to either the statin group (n=89) or to the non-statin group (n=105). Median initial wound size was 0.6cm
(Interquartile range (IQR): 0.15-2.4) (p=0.684). In the statin group, 54 (60.6%) patients progressed to complete wound healing compared with 47 (44.7%) in the non-statin group (p=0.027). Median rate of wound healing was 6.7×10
cm
/day (IQR: 1.5×10
-2.6×10
) compared with 3.8×10
3cm
/day (IQR: 1.7×10
-1.3×10
) in the non-statin group (p=0.773). Increased age and a higher number of comorbidities were reported in the statin group (p<0.001), respectively). A total of seven patients required amputation: five patients in the statin group and two patients in the non-statin group (p=0.250).
This study revealed increased progression to wound healing in patients who were taking statins. The influence of statins on wound healing is promising, but future trials are needed to justify use of this medication class independent of cardiovascular benefit and exclusively for wound healing.
Background
Genital‐based gender affirmation surgery is a physically demanding procedure requiring extensive postoperative pain management. However, perioperative opioid use for these procedures is ...relatively understudied.
Objectives
This study analyzes whether intravenous patient‐controlled analgesia (PCA) enhances pain control after penile inversion vaginoplasty (PIV) in the setting of enhanced recovery after surgery (ERAS) protocols, and whether non‐PCA (NCA)‐based regimens could reduce postoperative opioid use.
Methods
All patients undergoing PIV with ERAS protocols by a single provider from December 2018 to November 2020 were retrospectively reviewed. Patient demographics, comorbid conditions, pain scores, length of stay (LOS), and opioid usage during their hospitalization were collected. Postoperative opioid use and pain scores were compared between PCA and NCA patient cohorts.
Results
A total of 61 patients were included. 30 patients received intravenous PCA postoperatively, and 31 patients used NCA‐based narcotic pain control. All patients underwent ERAS protocol perioperatively. Average patient age was 34.5 years (SD 11.9) in the PCA cohort and 37.6 years (SD 11.9) in the NCA cohort (p = 0.242). Average total postoperative opioid use during hospital stay was reduced by 53.7% in the NCA cohort, with an average use of 501.6 morphine milligram equivalents (MME) (SD 410.3) among PCA patients and an average use of 232.0 MME (SD 216.5) among NCA patients (p = 0.003). Daily average pain scores for postoperative days 1 to 6 did not differ between the PCA and NCA patient groups (p > 0.05). Average hospital LOS was shorter among NCA patients, 6.2 days (SD 1.0) versus 7.3 days (SD 1.4), respectively, (p < 0.001).
Discussion
In combination with an ERAS non‐narcotic pain control protocol, it may be possible to reduce opioid use by more than 50% and shorten length of postoperative hospital stay among patients by implementing NCA pain management protocols.
Conclusion
Minimizing postoperative opioid consumption after PIV will benefit patients and their sustained well‐being.
