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Retrouvey H, Ipaktchi K, Lauder A. Evidence-based postoperative replantation protocols. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03706-8. [PMID: 37639003 DOI: 10.1007/s00590-023-03706-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/18/2023] [Indexed: 08/29/2023]
Abstract
Postoperative care is essential to upper extremity replantation success and includes careful and frequent monitoring of the replanted part. During this period, pharmacologic agents such as antithrombotic and anticoagulants may prevent complications such as arterial thrombosis and venous congestion. Dressings and therapy can also impact short- and long-term outcomes following replantation. This article reviews the literature to provide guidance for postoperative protocols following upper extremity replantation.
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Affiliation(s)
- Helene Retrouvey
- Division of Orthopedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, 12631 E. 17th Avenue, Academic Office 1, Mail Stop B202, Aurora, CO, 80045, USA.
| | - Kyros Ipaktchi
- Division of Orthopedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, 12631 E. 17th Avenue, Academic Office 1, Mail Stop B202, Aurora, CO, 80045, USA
| | - Alexander Lauder
- Division of Orthopedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, 12631 E. 17th Avenue, Academic Office 1, Mail Stop B202, Aurora, CO, 80045, USA
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Postoperative Digit and Hand Replantation Protocols: A Review of the Literature. J Am Acad Orthop Surg 2021; 29:e732-e742. [PMID: 34185029 DOI: 10.5435/jaaos-d-20-01176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 06/03/2021] [Indexed: 02/01/2023] Open
Abstract
Successful replantation and revascularization of the hand and digit require a skilled team with urgent access to an operating room with microsurgical capabilities. Although careful indications and surgical techniques contribute to success, postoperative management also plays a vital role in the survival of a replanted digit. Previous research has assessed surgical efficiency and techniques to conduct these procedures, but few studies evaluate postoperative protocols to care for patients undergoing these procedures. Because of the lack of high-level evidence specific to replantation, many common postoperative practices related to monitoring, anticoagulation, and diet have been inferred from elective microsurgical procedures, despite notable differences in operating conditions. The highest level of evidence pertaining to digital replantation was found with the use of peripheral nerve blockade, leeching/bleeding, and nicotine use. This review provides an in-depth evaluation of the literature and insight into the rationale and level of evidence that support each postoperative intervention. It highlights institutional variability and a paucity of high-level evidence pertaining to this topic while identifying the areas of future research.
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Bosselmann T, Kolbenschlag J, Goertz O, Zahn P, Prantl L, Lehnhardt M, Behr B, Sogorski A. Improvement of Superficial and Deep Cutaneous Microcirculation Due to Axillary Plexus Anesthesia Impaired by Smoking. J Clin Med 2021; 10:2114. [PMID: 34068862 PMCID: PMC8153641 DOI: 10.3390/jcm10102114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/03/2021] [Accepted: 05/10/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Understanding microvascular physiology is key to any reconstructive procedure. Current concepts in anesthesia increasingly involve regional peripheral nerve blockade during microvascular reconstructive procedures. Whereas favorable effects on perfusion due to these techniques have been reported earlier, little evidence focusing on its effects in most peripheral vascular compartments is available. METHODS A total of 30 patients who were to receive axillary plexus blockade (APB) were included. Microcirculatory assessment of the dependent extremity was conducted utilizing combined laser-Doppler flowmetry and white light spectroscopy. Two probes (1-2 and 7-8 mm penetration depth) were used to assess changes in microcirculation. RESULTS APB resulted in significant changes to both superficial and deep cutaneous microcirculation. Changes in blood flow were most prominent in superficial layers with a maximum increase of +617% compared to baseline values. Significantly lower values of +292% were observed in deep measurements. Consecutively, a significant enhancement in tissue oxygen saturation was observed. Further analysis revealed a significant impairment of perfusion characteristics due to reported nicotine consumption (max Bf: +936% vs. +176%). CONCLUSION Cutaneous microcirculation is strongly affected by APB, with significant differences regarding microvascular anatomy and vascular physiology. Smoking significantly diminishes the elicited improvements in perfusion. Our findings could influence reconstructive strategies as well as dependent perioperative anesthetic management.
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Affiliation(s)
- Talia Bosselmann
- Center of Plastic, Aesthetic, Hand and Reconstructive Surgery, University Hospital of Regensburg, 93053 Regensburg, Germany;
| | - Jonas Kolbenschlag
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany;
| | - Ole Goertz
- Department of Plastic Surgery and Hand Surgery, Burn Center, BG Universitätsklinikum Bergmannsheil Bochum, Ruhr-University Bochum, 44789 Bochum, Germany; (O.G.); (M.L.); (B.B.); (A.S.)
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Martin-Luther-Hospital, 14193 Berlin, Germany
| | - Peter Zahn
- Department of Anesthesiology, Intensive Care Medicine, Palliative and Pain Medicine, BG Universitätsklinikum Bergmannsheil Bochum, Ruhr-University Bochum, 44789 Bochum, Germany;
| | - Lukas Prantl
- Center of Plastic, Aesthetic, Hand and Reconstructive Surgery, University Hospital of Regensburg, 93053 Regensburg, Germany;
| | - Marcus Lehnhardt
- Department of Plastic Surgery and Hand Surgery, Burn Center, BG Universitätsklinikum Bergmannsheil Bochum, Ruhr-University Bochum, 44789 Bochum, Germany; (O.G.); (M.L.); (B.B.); (A.S.)
| | - Björn Behr
- Department of Plastic Surgery and Hand Surgery, Burn Center, BG Universitätsklinikum Bergmannsheil Bochum, Ruhr-University Bochum, 44789 Bochum, Germany; (O.G.); (M.L.); (B.B.); (A.S.)
| | - Alexander Sogorski
- Department of Plastic Surgery and Hand Surgery, Burn Center, BG Universitätsklinikum Bergmannsheil Bochum, Ruhr-University Bochum, 44789 Bochum, Germany; (O.G.); (M.L.); (B.B.); (A.S.)
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Sanghai S, Abbott NJ, Dewland TA, Henrikson CA, Elman MR, Wollenberg M, Ivie R, Gonzalez-Sotomayor J, Nazer B. Stellate Ganglion Blockade With Continuous Infusion Versus Single Injection for Treatment of Ventricular Arrhythmia Storm. JACC Clin Electrophysiol 2020; 7:452-460. [PMID: 33358672 DOI: 10.1016/j.jacep.2020.09.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 09/04/2020] [Accepted: 09/05/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES This study sought to compare the efficacy and safety of single-injection stellate ganglion block (SGB) with a novel continuous-infusion SGB procedure. BACKGROUND SGB for ventricular arrhythmia (VA) storm is typically performed with a single injection of local anesthetic agents. METHODS Eighteen patients underwent left-sided SGB (9 single injection and 9 continuous infusion). The number of implantable cardioverter-defibrillator therapies and sustained VAs/24 h were compared between the pre-SGB and post-SGB periods. Adverse effects of SGB and in-hospital outcomes were also compared. RESULTS The mean age was 61.1 ± 13.7 years. The presenting arrhythmia was ventricular tachycardia in 13 (72%) patients, ventricular fibrillation in 4 (22%), and both in 1 (6%). Single-injection SGB reduced VA/24 h by a median of 0.3 (interquartile range: 0.2 to 0.9), which was a 45% reduction (p = 0.008), resulting in 5 of 9 patients with no recurrent VA. Continuous-infusion SGB reduced VA/24 h by a median of 2.0 (interquartile range: 1.3 to 3.0), which was a 94% reduction (p = 0.004), resulting in 7 of 9 patients with no recurrent VA (p = 0.006 for comparison with single injection). Transient left arm weakness and voice hoarseness were each noted in 1 patient in both groups. Repeat SGB was required in 4 (44%) patients in the single-injection group. In-hospital outcomes were similar between the groups. CONCLUSIONS In patients with VA storm, SGB performed via both continuous-infusion and single-injection approaches provided significant reductions in VA burden. Compared to single-injection SGB, continuous-infusion was associated with a greater reduction in VA burden and similar adverse events, without the need for repeat procedures.
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Affiliation(s)
- Saket Sanghai
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Nicholas J Abbott
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Thomas A Dewland
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Charles A Henrikson
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Miriam R Elman
- Biostatistics and Design Program, Oregon Health and Science University-Portland State University School of Public Health, Portland, Oregon, USA
| | - Michael Wollenberg
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Ryan Ivie
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Julio Gonzalez-Sotomayor
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Babak Nazer
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA.
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Park EP, Le JM, Gigliotti J, Feinstein J, Ying YP, Morlandt AB. Does Supplemental Regional Anesthesia Decrease Length of Stay and Opioid Use for Patients Undergoing Head and Neck Microvascular Reconstruction? J Oral Maxillofac Surg 2020; 79:712-721. [PMID: 32976833 DOI: 10.1016/j.joms.2020.08.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 08/25/2020] [Accepted: 08/25/2020] [Indexed: 12/01/2022]
Abstract
PURPOSE The purpose of this study was to compare length of hospital stay and opioid usage among head and neck surgery (HNS) patients treated with and without regional anesthesia for microvascular free-flap donor sites. METHODS The authors performed a retrospective cohort study for HNS patients undergoing microvascular free-flap reconstruction. The control group received no regional anesthesia. The experimental group had a regional anesthesia nerve block performed immediately before surgery. The primary outcome variable was length of stay, and the secondary outcome variable was total morphine milliequivalents. The data were analyzed using Student t tests, analysis of variance, Mann-Whitney U test, Kruskal-Wallis test, χ2 test, and multiple linear regression. RESULTS The study sample was composed of 148 patients with a mean age of 58.1 years. The mean length of stay for the control group was 6.74 ± 1.57 days, compared with the experimental group at 5.84 ± 1.01 days (P < .0001). The mean morphine milliequivalent was 256.5 ± 164.6 mg for the control group and 208.9 ± 164.8 mg for the experimental group (P = .56). Importantly, the demographics, pathology spectrum, flap selection, duration of procedure, and complication rate were similar in both groups. CONCLUSIONS This study demonstrates that for HNS patients undergoing microvascular reconstruction, regional nerve block at the donor site is associated with significantly shorter hospital stays. Although there was a trend toward decreased opioid usage in the regional anesthesia group, these results did not reach statistical significance. Consideration should be given to incorporate regional anesthesia techniques into early recovery after surgery protocols for centers performing high-volume head and neck microvascular reconstruction.
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Affiliation(s)
- Earl Peter Park
- Assistant Professor, Department of Oral & Maxillofacial Surgery, Louisiana State University Health Science Center, New Orleans, LA.
| | - John Minh Le
- Surgical Resident, Department of Oral & Maxillofacial Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Jordan Gigliotti
- Assistant Professor, Department of Oral & Maxillofacial Surgery, McGill University, Montreal, Canada
| | - Joel Feinstein
- Associate Professor and Director of Regional Anesthesia for University Hospitals, Department of Anesthesia and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Yedeh P Ying
- Assistant Professor, Department of Oral & Maxillofacial Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Anthony B Morlandt
- Associate Professor and Section Chief of Oral Oncology and Microvascular Surgery, Department of Oral & Maxillofacial Surgery, University of Alabama at Birmingham, Birmingham, AL
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Mastication Muscle Suppression by the Mandibular Branch of Trigeminal Nerve Catheter-Based, Ultrasound-Guided Block: A Case Report. ARCHIVES OF NEUROSCIENCE 2020. [DOI: 10.5812/ans.104360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Ultrasound-guided nerve blocks have enhanced our abilities to selectively and effectively suppress certain nerves to accomplish specific goals, including blockade a localized seizure muscle movement without affecting the seizure threshold or level of the consciousness. Case Presentation: This is a case report of the blockade of the movement of a chewing muscle by the continuous (catheter-based) mandibular nerve block in a 27 years old man with high-frequency partial seizures in facial muscles who was a candidate for seizure focus ablation. An out-of-plane approach was used to insert a catheter near the mandibular nerve to provide intermittent or continuous peripheral nerve block. This report demonstrated that a continuous block of the mandibular nerve could effectively facilitate the seizure focus mapping and ablation. Conclusions: We can selectively suppress the contractures of a certain muscle in partial seizures by a continuous block of the responsible nerve. This blockade can facilitate seizure focus mapping and ablation.
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